Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 07
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: 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 2346 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 9 9 225.653176 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 9 9 225.653176 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 4 4 4.000000 $59.7200 $14.9300
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 4 4 4.000000 $76.8000 $19.2000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 4 4 4.000000 $41.6800 $10.4200
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 11 11 5.079452 $111.5000 $21.9500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 19 19 5.309590 $46.4600 $8.7500
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 2 2 2.000000 $16.1200 $8.0600
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 19 19 5.309590 $115.9800 $21.8400
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 2 2 2.000000 $57.8000 $28.9000
AUDE -92585 AUD EVOKED RESPONSE (COMP) 3 3 3.000000 $195.4200 $65.1400
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 3 3 3.000000 $115.1100 $38.3700
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 18 18 4.309590 $98.7000 $22.9000
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 1.000000 $25.5300 $25.5300
EXIT -EXIT EXIT ASSESSMENT 27 27 11.909058 $595.4500 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 2 2 2.005479 $150.4100 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 2 2 0.068493 $5.1400 $75.0100
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 3 3 2.068493 $114.8000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 30 30 40.054790 $3004.1300 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 4 4 0.161644 $12.1200 $74.9800
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 43 43 32.947944 $1828.6100 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 19 19 2.649316 $198.7000 $75.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 1 1 1.000000 $51.0500 $51.0500
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 3 3 1.611111 $82.2500 $51.0500
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 1 1 0.144444 $7.3700 $51.0300
PSTH -97001 EVAL BY LICENSED PT, INITIAL 3 3 0.666667 $34.0400 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 2 2 2.000000 $102.1000 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 21 21 6.808447 $347.5600 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 2 2 1.066667 $54.4600 $51.0500
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Subtotal (Total Children Is Unduplicated) 138 253 148.170775 $7548.9900 $50.9500
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 0.098630 $493.0000 $4998.4800
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 9 9 6.312047 $315.6000 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 116 146 80.790283 $4039.5600 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 2 3 3.677777 $91.9400 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 253 496 1525.525874 $76276.4600 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 9 19 31.752382 $793.8100 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 11 13 41.290478 $2064.5400 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 2 6.133334 $153.3400 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 7 9 23.114287 $1155.7200 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 12 13 50.347620 $2517.4000 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 3 10.952381 $273.8100 $25.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 13.142857 $657.1500 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 886 1202 10489.787790 $524489.6400 $50.0000
INTR -T1013 INTERPRETER 11 12 128.142856 $6407.1500 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 1 1 0.142857 $1.4300 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 8 9 59.000000 $4214.9700 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 12 15 122.928571 $8782.0200 $71.4400
PHY -97110HM PT SESSION BY PT ASST 1 1 13.142857 $751.2500 $57.1600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 48 58 443.785714 $31704.0900 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 8.285715 $115.0100 $13.8800
TRAV -TRAVS Travel by mile 49 69 547.095234 $243.4600 $0.4400
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Subtotal (Total Children Is Unduplicated) 902 2084 13605.449544 $665541.3000 $48.9200
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Total 2346 13979.273495 $673090.2900 $48.1500
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Number of Children (Unduplicated) With at Least One Authorization 925