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: 07-01-16 and 09-30-16 Date of Report: 10-26-16 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 3284 FSPSA's found
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
SCONLY-SCONLY *SERVICE COORDINATION ONLY 2 2 0.266667 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 12 13 66.911905 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 14 15 67.178572 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 1 1 1.000000 $48.5000 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 2 2 0.705555 $33.2200 $47.0900
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 0.511111 $9.8100 $19.2000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 0.744444 $7.7600 $10.4200
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 68 69 48.069839 $1055.1300 $21.9500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 3 3 12.243651 $107.1300 $8.7500
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 0.161111 $3.5200 $21.8400
AUDE -92585 AUD EVOKED RESPONSE (COMP) 2 2 0.072222 $4.7000 $65.1200
AUDE -V5010 ASSESSMENT FOR HEARING AID 6 8 3.011111 $140.9200 $46.8000
AUDE -V5090 DISPENSING FEE PER HEARING AID 6 7 2.161110 $258.4600 $119.5900
EVAL -96111 DEVELOPMENTAL EVALUATION 2 2 2.677778 $133.8900 $50.0000
EXIT -EXIT EXIT ASSESSMENT 6 6 6.844444 $342.2200 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 3 3 1.883333 $141.2500 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 18 27 23.094442 $1732.0700 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 45 67 62.120848 $4659.0300 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 2 2 0.666667 $50.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 27 34 22.644443 $1698.3200 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 69 107 83.587509 $4639.0500 $55.5000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 28 28 50.522222 $2803.9800 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 14 14 25.500000 $1912.5000 $75.0000
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Subtotal (Total Children Is Unduplicated) 187 385 348.221840 $19781.4600 $56.8100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 7 10 5.811110 $29055.0000 $4999.9100
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 3 3 1.538888 $76.9400 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 52 52 23.788397 $1189.4000 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 3 3 7.093651 $507.9700 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 12 12 11.576985 $2769.2200 $239.2000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 55 59 314.388891 $15719.4600 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 2 3 3.022222 $75.5600 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 269 412 639.269041 $31963.4200 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 27 37 49.033331 $1225.8300 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 19 24 84.457936 $6192.4600 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 22 25 99.592062 $2489.8000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 668 915 5767.590457 $288379.7500 $50.0000
INTR -T1013 INTERPRETER 1 1 2.000000 $100.0000 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 670 1313 6463.361090 $64633.6500 $10.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 2 3 0.822222 $53.4400 $65.0000
SENS -V5050 IN EAR MONAURAL HEARING AID 2 3 1.644444 $389.9200 $237.1100
SENS -V5140 BEHIND THE EAR BINAURAL HEARING AI 2 2 1.261111 $598.0600 $474.2400
SENS -V5264 EARMOLD 5 6 3.794443 $68.3000 $18.0000
TRAV -TRAVS Travel by mile 1 1 3.642857 $1.6200 $0.4500
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Subtotal (Total Children Is Unduplicated) 681 2884 13483.689138 $445489.7900 $33.0400
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Total 3284 13899.089550 $465271.2500 $33.4700
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Number of Children (Unduplicated) With at Least One Authorization 683