Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 55
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: 10-01-17 and 12-31-17 Date of Report: 02-03-18 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 4149 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 48 53 43.666668 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 48 53 43.666668 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 2 0.252055 $2.0800 $8.2600
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 2 0.252055 $6.3800 $25.3000
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 3.966666 $456.1600 $115.0000
EVAL -96111 DEVELOPMENTAL EVALUATION 13 17 3.315522 $165.7900 $50.0000
EXIT -EXIT EXIT ASSESSMENT 12 12 10.186302 $509.3100 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 5 5 6.010958 $450.8300 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 6 6 8.010958 $600.8300 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 2 2 2.005479 $150.4100 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 3 3 4.005479 $222.3100 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 163 163 268.924060 $20169.3400 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 120 120 214.345983 $16075.9700 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 70 70 97.610951 $7320.8500 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 32 32 52.032874 $2887.8300 $55.5000
OCTF -97168 OT RE-EVAL EST PLAN CARE 69 79 27.032135 $1379.9800 $51.0500
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 0.177778 $9.0800 $51.0600
OCTH -97166 OT EVAL MODERATE COMPLEXITY 12 13 5.383333 $274.8200 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 31 34 15.571974 $794.9500 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 35 41 12.282574 $627.0300 $51.0500
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 0.455556 $23.2600 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 11 13 5.090943 $259.8900 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 27 27 13.037520 $665.5700 $51.0500
SPCH -92521 EVAL OF SPEECH FLUENCY 1 1 1.000000 $51.0500 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 100 113 47.199847 $2409.5500 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 16 18 7.066666 $360.7500 $51.0500
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Subtotal (Total Children Is Unduplicated) 426 778 805.217668 $55873.9900 $69.3900
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 6 8 5.323289 $26616.5000 $5000.0100
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 2 1.022223 $51.1200 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 0.455556 $104.7900 $230.0200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 15 21 8.681203 $434.0600 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 7 7 6.077776 $151.9400 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 228 316 262.425386 $13121.2300 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 216 280 388.665085 $9716.6400 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 170 387 250.911089 $12545.4500 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 85 176 210.838890 $5270.9800 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 77 177 105.583326 $5279.1300 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 46 104 127.250000 $3181.2500 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 182 228 196.356346 $9817.8100 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 186 231 331.314290 $8282.8700 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 6 8 70.857143 $1771.4300 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 303 409 2974.701581 $148735.1700 $50.0000
INTR -T1013 INTERPRETER 1 2 1.022222 $51.1100 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 165 212 1345.125033 $96095.7800 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 149 204 1609.032144 $92036.6900 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 92 120 871.295241 $62245.3700 $71.4400
PHY -97110HM PT SESSION BY PT ASST 71 103 721.192859 $41223.4000 $57.1600
SENS -V5060 BEHIND EAR HEARING AID
2 2 2.000000 $456.0000 $228.0000
SENS -V5264 EARMOLD 4 5 4.988889 $89.8000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 238 309 2505.059192 $178961.6100 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 5 6 45.714286 $634.5200 $13.8800
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Subtotal (Total Children Is Unduplicated) 648 3318 12045.893049 $716874.6200 $59.5100
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Total 4149 12894.777385 $772748.6100 $59.9300
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Number of Children (Unduplicated) With at Least One Authorization 780