Summary Report for FSPSAs Initiated During the Report Period Statewide
This report shows the total number of units/fees for FSPSAs initiated during the report period.
(i.e., start 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 starting 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 24275 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
CASE -CASE NON-TCM CASE MANAGEMENT 1 1 0.250000 $9.2500 $37.0000
SCONLY-SCONLY *SERVICE COORDINATION ONLY 148 149 229.985813 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 15 15 51.025397 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 8 8 9.234922 $341.7000 $37.0000
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Subtotal (Total Children Is Unduplicated) 169 173 290.496132 $350.9500 $1.2100
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 82 103 85.404494 $4142.1300 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 13 13 5.205555 $245.1300 $47.0900
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 6 6 3.013492 $44.9900 $14.9300
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 215 216 172.152382 $3305.3300 $19.2000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 6 6 4.446825 $46.3400 $10.4200
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 42 43 33.042868 $725.2900 $21.9500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 11 11 5.161893 $45.1700 $8.7500
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 5 5 2.013492 $16.2300 $8.0600
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 11 11 5.161893 $112.7400 $21.8400
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 5 5 2.013492 $58.1900 $28.9000
AUDE -92585 AUD EVOKED RESPONSE (COMP) 19 21 7.702382 $501.7400 $65.1400
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 1 1 0.046575 $1.7900 $38.3900
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 6 6 1.715068 $39.2800 $22.9000
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 17 17 11.069047 $282.5900 $25.5300
AUDE -V5010 ASSESSMENT FOR HEARING AID 9 11 15.930953 $745.5700 $46.8000
AUDE -V5090 DISPENSING FEE PER HEARING AID 10 10 15.787193 $1888.1500 $119.6000
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 3 3 3.533333 $441.6600 $125.0000
EVAL -96111 DEVELOPMENTAL EVALUATION 12 14 6.571611 $328.5800 $50.0000
EXIT -EXIT EXIT ASSESSMENT 247 258 437.324675 $21866.2200 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 1 1 0.227778 $17.0900 $75.0100
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 36 40 39.764532 $2982.3400 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 19 30 16.244290 $1218.3200 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 16 16 16.793379 $1259.5100 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 22 25 34.458653 $2584.4000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 49 62 74.678647 $4144.6600 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 469 473 460.472787 $34535.7700 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 181 181 161.225402 $12092.0400 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 120 120 125.431488 $9407.4200 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 433 434 507.457606 $28163.9900 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 146 166 182.845726 $13713.4400 $75.0000
NURS -T1001 NURSING ASSESSMENT 1 1 3.285714 $164.2900 $50.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 10 12 50.142857 $2507.1500 $50.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 28 29 11.858038 $605.3700 $51.0500
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 239 249 146.024525 $7454.5400 $51.0500
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 37 39 10.134781 $517.3800 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 173 179 237.521041 $12125.4400 $51.0500
SCREEN-T1023 SCREENING 30 30 26.293694 $1314.6800 $50.0000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 3 1.977778 $30.8500 $15.6000
SPCH -92521 EVAL OF SPEECH FLUENCY 10 10 7.202740 $367.7000 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 6 6 3.623288 $184.9700 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 282 291 242.974655 $12403.8600 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 12 12 8.456165 $431.6800 $51.0500
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Subtotal (Total Children Is Unduplicated) 2003 3169 3186.392787 $183063.9500 $57.4500
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 100 116 76.514280 $382572.5000 $5000.0100
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 5 5 3.566666 $178.3300 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 15 15 102.786519 $5139.3300 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 4 4 2.272223 $162.7200 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 24 24 8.681277 $2076.5400 $239.2000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 734 907 558.708180 $27935.5400 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 87 93 47.882436 $1197.0600 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1777 2175 3009.820978 $150490.9300 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 128 140 341.534922 $8538.3800 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 560 672 1050.506657 $52525.2800 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 28 38 43.804760 $1095.1200 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 451 493 749.986271 $37499.2800 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 12 14 16.589681 $414.7400 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1230 1291 1614.973854 $80748.6600 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 115 135 343.007938 $8575.2100 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 8 10 27.997621 $2052.8000 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 176 192 2290.534918 $57263.3600 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 41.428571 $2071.4300 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 6 9 36.452379 $1822.6200 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 4781 5225 33716.341613 $1685816.1100 $50.0000
INTR -T1013 INTERPRETER 116 137 567.729386 $28386.4400 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 2866 4481 21106.833138 $211068.1500 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 657 725 4112.456292 $293793.7400 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 101 111 598.766666 $34249.4800 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 698 752 4156.338506 $296928.6900 $71.4400
PHY -97110HM PT SESSION BY PT ASST 52 56 325.796031 $18622.4900 $57.1600
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 0.128767 $8.3700 $65.0200
SENS -V5050 IN EAR MONAURAL HEARING AID 7 7 7.224658 $1713.1200 $237.1200
SENS -V5140 BEHIND THE EAR BINAURAL HEARING AI 6 8 12.740008 $6041.8200 $474.2400
SENS -V5264 EARMOLD 22 24 30.968406 $557.4300 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1105 1213 7230.819119 $516569.5200 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 2 7.000000 $400.4000 $57.2000
SPL -92508 GROUP SPL SESSION PER CHILD 24 25 173.059526 $2402.0700 $13.8800
TRAV -TRAVS Travel by mile 1047 1832 133097.057065 $59228.1900 $0.4500
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Subtotal (Total Children Is Unduplicated) 6553 20933 215510.309312 $3978145.8200 $18.4600
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Total 24275 218987.198231 $4161560.7200 $19.0000
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Number of Children (Unduplicated) With at Least One Authorization 6949