Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 54
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 5072 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
CASE -CASE NON-TCM CASE MANAGEMENT 1 1 0.250000 $9.2500 $37.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 12 13 62.931745 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 13 14 63.181745 $9.2500 $0.1500
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 46 58 38.291322 $1857.1200 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 37 39 30.117456 $1418.2100 $47.0900
AUDE -92585 AUD EVOKED RESPONSE (COMP) 26 30 11.799544 $768.6300 $65.1400
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 1.000000 $22.9000 $22.9000
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 33 34 21.512780 $549.2100 $25.5300
AUDE -V5010 ASSESSMENT FOR HEARING AID 8 11 5.833333 $273.0000 $46.8000
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 2.483333 $297.0000 $119.6000
EVAL -96111 DEVELOPMENTAL EVALUATION 1 1 1.000000 $50.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 55 62 86.480740 $4324.0200 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 2 3 1.489955 $111.7400 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 6 7 6.192998 $464.4700 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 3 3 1.244444 $93.3300 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 3 3 1.688889 $126.6700 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 6 7 5.537443 $415.3100 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 4 4 4.746575 $263.4400 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 2 4 0.797260 $59.8000 $75.0000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 2 3 0.457534 $34.3200 $75.0100
PSTH -97001 EVAL BY LICENSED PT, INITIAL 1 1 0.844444 $43.1100 $51.0500
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 3 1.977778 $30.8500 $15.6000
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.666667 $34.0400 $51.0500
VISF -92499 VISION EVALUATION FUNCTIONAL 3 3 1.711111 $85.5600 $50.0000
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Subtotal (Total Children Is Unduplicated) 204 281 225.873606 $11322.7000 $50.1300
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 58 86 34.925951 $174630.0000 $5000.0100
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 1 2 1.022222 $51.1100 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 2 3 1.055555 $52.7800 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 9 9 5.622222 $402.6100 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 8 8 55.388095 $13248.8100 $239.2000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 68 89 81.766278 $4088.3300 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 600 1053 1029.401210 $51469.8100 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 5 8 4.500000 $112.5000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 9 10 14.211111 $710.5600 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 7 8 16.455556 $822.7800 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 28 28 21.877778 $1093.8900 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 0.266667 $6.6700 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 2 3 4.200001 $307.9500 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 8 8 27.119048 $677.9800 $25.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 13 17 117.057142 $5852.8600 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 818 1146 7528.851883 $376442.7500 $50.0000
INTR -T1013 INTERPRETER 2 3 21.857143 $1092.8600 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 846 2208 9056.652166 $90566.5100 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 9 11 119.047620 $8504.7700 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 24 28 199.592064 $14258.8700 $71.4400
PHY -97110HM PT SESSION BY PT ASST 1 1 5.428571 $310.3000 $57.1600
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 2.000000 $474.2400 $237.1200
SENS -V5140 BEHIND THE EAR BINAURAL HEARING AI 4 6 2.466666 $1169.7600 $474.2300
SENS -V5264 EARMOLD 6 10 6.588889 $118.6000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 21 29 170.696827 $12194.5800 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 1.000000 $13.8800 $13.8800
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Subtotal (Total Children Is Unduplicated) 856 4777 18529.050665 $758675.7400 $40.9500
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Total 5072 18818.106016 $770007.7000 $40.9200
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Number of Children (Unduplicated) With at Least One Authorization 858