Summary Report for FSPSAs Ending During the Report Period Center: 01
This report shows the total number of units/fees for FSPSAs ending during the report period.
(i.e., end 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 ending between: 10-01-16 and 12-31-16 Date of Report: 02-04-17 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 4402 FSPSA's found
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
SCONLY-SCONLY *SERVICE COORDINATION ONLY 45 46 158.602380 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 1 1 11.857143 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 4 4 2.000000 $74.0000 $37.0000
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Subtotal (Total Children Is Unduplicated) 49 51 172.459523 $74.0000 $0.4300
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 13 14 7.813622 $378.9600 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 0.032877 $1.5500 $47.1200
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 0.377778 $8.2500 $21.8400
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 0.188889 $4.8200 $25.5300
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.188889 $8.8400 $46.8000
EVAL -96111 DEVELOPMENTAL EVALUATION 1 1 1.000000 $50.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 113 116 232.000000 $11600.0000 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 16 16 25.008219 $1875.6200 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 8 8 13.500000 $1012.5000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 12 12 19.500000 $1462.5000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 17 17 23.010959 $1277.1000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 165 167 404.161641 $30312.1400 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 65 65 136.078082 $10205.8600 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 46 46 75.506850 $5663.0100 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 214 214 494.598629 $27450.2200 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 88 106 149.124953 $11184.3500 $75.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 3 3 1.701370 $86.8600 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 14 14 10.075571 $514.3600 $51.0500
SPCH -92521 EVAL OF SPEECH FLUENCY 2 2 2.000000 $102.1000 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 13 13 36.328203 $1854.5500 $51.0500
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Subtotal (Total Children Is Unduplicated) 474 819 1634.196532 $105203.6000 $64.3800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 10 10 15.911535 $79557.0000 $4999.9600
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 11 11 19.505555 $975.2800 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 4.142857 $296.6700 $71.6100
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 170 188 184.655379 $9232.7500 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 5 5 3.886111 $97.1500 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 82 121 224.597148 $11229.8400 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 2 3 2.733334 $68.3400 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 14 14 86.456348 $4322.8100 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 23 24 77.849620 $3892.4900 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 33 35 51.791271 $2589.5700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 9.428571 $235.7200 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 550 590 3533.093045 $176654.5900 $50.0000
INTR -T1013 INTERPRETER 69 74 297.935909 $14896.8000 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 726 1060 4854.892626 $48548.9100 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 23 24 142.038097 $10147.2000 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 3 3 16.419048 $939.1700 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 53 59 345.461909 $24679.7900 $71.4400
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 1 1 0.377778 $44.7900 $118.5700
SENS -V5264 EARMOLD 1 1 0.377778 $6.8000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 82 92 524.976187 $37504.3100 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 3.857143 $53.5400 $13.8800
TRAV -TRAVS Travel by mile 836 1214 14254.234236 $6343.1300 $0.4500
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Subtotal (Total Children Is Unduplicated) 862 3532 24654.621485 $432316.6200 $17.5300
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Total 4402 26461.277540 $537594.2200 $20.3200
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Number of Children (Unduplicated) With at Least One Authorization 1043