Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 53
This report estimates subtotals of units and fees for the number of days of overlap between each included
FSPSA record and the user-selected report period. For example, if the FSPSA record authorizes services from
01/01/01 to 08/01/01, and the Report Period is selected as 01/01/01 to 03/01/01, this summary calculates
authorized units/fees for the 28 days of overlap (02/01/01 to 03/01/01). Note that service authorization periods
may range from 1 to 12 months and may vary in intensity from child to child.
FSPSAs overlapping: 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 8257 FSPSA's found of which 313 had no frequency modifier field, FORCE FREQ MODIFIER to 0
Services Cpt Code Number of Number of Total Units Total Fees Avg Fee
Children Records Overlapping Overlapping Per Unit Auth
Report Period Report Period
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
TCM -T1017TL TARGETED CASE MANAGEMENT 3 4 25.714285 $951.4300 $37.0000
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Subtotal (Total Children Is Unduplicated) 17 31 211.448811 $1067.7200 $5.0500
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 3 6 281.611111 $13658.1400 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 2 2 1.111111 $52.3200 $47.0900
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 1.277778 $13.3100 $10.4200
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 33 35 23.595238 $517.9200 $21.9500
AUDE -92585 AUD EVOKED RESPONSE (COMP) 3 3 2.950000 $192.1600 $65.1400
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 1 1 1.022222 $39.2200 $38.3700
AUDE -V5010 ASSESSMENT FOR HEARING AID 5 7 4.911112 $229.8400 $46.8000
AUDE -V5090 DISPENSING FEE PER HEARING AID 4 6 4.977777 $595.3300 $119.6000
EVAL -96111 DEVELOPMENTAL EVALUATION 3 5 10.388889 $519.4500 $50.0000
EXIT -EXIT EXIT ASSESSMENT 17 17 42.707718 $2135.3900 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 7 7 13.616668 $1021.2600 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 34 43 52.727778 $3954.5900 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 105 166 823.414550 $61756.1300 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 4 4 9.566667 $717.5000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 83 174 280.441397 $21033.0800 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 114 157 241.351060 $13395.0200 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 3 3 0.027778 $2.0900 $75.0600
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 8 12 11.872144 $890.4000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 3 3 4.011111 $300.8300 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 103 106 185.910651 $10318.0400 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 62 69 93.739278 $7030.4600 $75.0000
PDEO -T1024 *PSY-DEV EVAL OUTPATIENT, INITIAL 17 20 9.779223 $1466.8700 $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) 412 848 2113.477928 $140475.7700 $66.4700
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 15 21 78.124200 $390621.0000 $5000.0000
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 3 3 2.238888 $111.9400 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 98 103 94.950965 $4747.5400 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 3 3 1.422222 $101.8400 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 8 8 2.087878 $499.4300 $239.2000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 112 157 722.059557 $36102.9900 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 7 8 4.477779 $111.9500 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 348 649 1462.150804 $73107.5900 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 41 56 123.922220 $3098.0500 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 18 22 61.873015 $4536.5300 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 42 54 449.966670 $11249.1700 $25.0000
EIIF -T1024HN *EI INDIVIDUAL SESSION BY PROF 31 31 58.188889 $2909.4500 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 1002 2448 23093.328320 $1154666.8700 $50.0000
INTR -T1013 INTERPRETER 1 1 8.000000 $400.0000 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 811 2008 16898.484112 $168984.8700 $10.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 2 2 1.672223 $108.7000 $65.0000
SENS -V5050 IN EAR MONAURAL HEARING AID 2 2 3.344444 $793.0200 $237.1200
SENS -V5264 EARMOLD 5 8 8.483333 $152.7000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 2 3 15.142857 $1081.8100 $71.4400
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 579 1776 10385.238100 $5192.6200 $0.5000
TRAV -TRAVS Travel by mile 11 15 4706.813319 $2094.5300 $0.4500
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Subtotal (Total Children Is Unduplicated) 1063 7378 58181.969795 $1860672.5800 $31.9800
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Total 8257 60506.896534 $2002216.0600 $33.0900
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Number of Children (Unduplicated) With at Least One Authorization 1071