Summary Report for FSPSAs Initiated During the Report Period Center: 53
This report shows the total number of units/fees for FSPSAs initiated during the report period.
(i.e., start date of service authorization occurs during the report period). This report does not
represent all FSPSAs that overlap the report period. Note that service authorization periods may
range from 1 to 12 months and may vary in intensity from child to child.
FSPSAs starting between: 07-01-15 and 06-30-16 Date of Report: 08-06-16 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 4083 FSPSA's found of which 98 had no frequency modifier field, FORCE FREQ MODIFIER to 0
Services Cpt Code Number of Number of Total Units Total Cost of Avg Fee
Children Records Authorized Auth Services Per Unit Auth
Service Coordination, Class # 01
CASE -CASE NON-TCM CASE MANAGEMENT 2 4 3.142857 $116.2900 $37.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 15 23 182.591669 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 16 27 185.734526 $116.2900 $0.6300
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 3 6 281.611111 $13658.1400 $48.5000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 1.277778 $13.3100 $10.4200
EVAL -96111 DEVELOPMENTAL EVALUATION 2 4 10.000000 $500.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 17 17 42.707718 $2135.3900 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 5 7 3.972222 $297.9200 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 25 31 19.350001 $1451.2600 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 9 15 5.316665 $398.7400 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 26 29 13.855557 $768.9900 $55.5000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 1 1 1.500000 $83.2500 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 3 5 3.055556 $229.1700 $75.0000
PDEO -T1024 *PSY-DEV EVAL OUTPATIENT, INITIAL 8 10 2.682876 $402.4200 $150.0000
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 1 1 12.466667 $636.4300 $51.0500
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Subtotal (Total Children Is Unduplicated) 73 127 397.796151 $20575.0100 $51.7200
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 4 1.949999 $9749.5000 $4999.7500
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 3 3 2.238888 $111.9400 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 96 101 91.984299 $4599.2100 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 0.772222 $55.3000 $71.6100
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 111 156 721.059557 $36052.9900 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 7 8 4.477779 $111.9500 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 345 641 1442.298422 $72114.9700 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 41 56 123.922220 $3098.0500 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 4 4 14.263491 $1045.7900 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 2.571429 $64.2900 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 47 63 409.450792 $20472.5600 $50.0000
INTR -T1013 INTERPRETER 1 1 8.000000 $400.0000 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 811 1984 16713.069823 $167130.7300 $10.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 0.705556 $45.8600 $65.0000
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 382 893 5839.443421 $2919.7200 $0.5000
TRAV -TRAVS Travel by mile 11 12 4687.460938 $2085.9200 $0.4500
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Subtotal (Total Children Is Unduplicated) 950 3929 30063.668836 $320058.7600 $10.6500
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Total 4083 30647.199513 $340750.0600 $11.1200
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Number of Children (Unduplicated) With at Least One Authorization 954