Summary Report for FSPSAs Initiated During the Report Period Center: 02
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: 01-01-17 and 03-31-17 Date of Report: 05-05-17 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1965 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 4 4 5.211111 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 4 4 5.211111 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 28 30 5.800303 $281.3000 $48.5000
EXIT -EXIT EXIT ASSESSMENT 50 50 34.094522 $1704.7200 $50.0000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 2 2 0.008220 $0.6200 $74.8200
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 2 2 4.000000 $300.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 4 4 6.004110 $333.2300 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 1 1 0.004110 $0.3100 $74.8200
NURS -T1001 NURSING ASSESSMENT 1 1 0.002740 $0.1400 $49.2700
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 1 1 0.158904 $8.1100 $51.0500
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 1 1 0.158904 $8.1100 $51.0500
OCTH -97165 OT EVAL LOW COMPLEXITY 2 3 0.602132 $30.7400 $51.0500
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 2 2 0.317808 $16.2200 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 1 1 0.205479 $10.4900 $51.0600
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 0.161644 $8.2500 $51.0400
PSTH -97162 PT EVAL MODERATE COMPLEXITY 2 2 0.353425 $18.0400 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 5 5 1.234019 $63.0000 $51.0500
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Subtotal (Total Children Is Unduplicated) 87 106 53.106320 $2783.2700 $52.4100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 6 6 1.634702 $8173.0000 $4999.6900
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 64 79 15.680205 $783.9700 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 190 226 320.339027 $16016.9400 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 0.166667 $4.1700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 57 66 94.583335 $4729.1800 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 34 35 49.533335 $2476.6800 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 143 150 198.733330 $9936.6500 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 0.666667 $16.6700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 8 8 53.071427 $2653.5800 $50.0000
INTR -T1013 INTERPRETER 17 23 52.290460 $2614.5100 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 267 434 1429.243316 $14292.4200 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 10 11 73.500000 $5250.8300 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 7 7 77.571428 $5541.7000 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 14 16 112.357142 $8026.8000 $71.4400
TRAV -TRAVS Travel by mile 335 792 98135.446777 $43670.2800 $0.4500
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Subtotal (Total Children Is Unduplicated) 347 1855 100614.817818 $124187.3500 $1.2300
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Total 1965 100673.135249 $126970.6200 $1.2600
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Number of Children (Unduplicated) With at Least One Authorization 368