Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 02
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: 01-01-18 and 03-31-18 Date of Report: 05-05-18 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 5563 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 1 1 1.300000 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 1 1 1.300000 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 61 88 39.008476 $1891.9300 $48.5000
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 1 1.033333 $18.5200 $17.9200
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 0.221918 $4.7400 $21.3500
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 4 5 1.859818 $23.4500 $12.6100
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 2 2 0.396575 $8.5500 $21.5500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 2 2 1.288585 $10.6400 $8.2600
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 2 2 1.288585 $32.6100 $25.3100
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 1 1 8.285714 $384.6200 $46.4200
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 2 2 2.066667 $42.7400 $20.6800
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 12.857143 $578.5700 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 13.350294 $1535.2800 $115.0000
EXIT -EXIT EXIT ASSESSMENT 93 94 118.810503 $5940.5200 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 3 3 2.010958 $150.8300 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 2 2 2.005479 $150.4100 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 4 4 6.005479 $450.4100 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 5 5 6.010958 $333.6100 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 86 86 121.658894 $9124.4600 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 52 52 77.158899 $5786.9400 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 94 95 134.647933 $7472.9900 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 38 38 66.027395 $4952.0600 $75.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 6 7 2.313242 $118.0900 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 15 18 3.450229 $176.1500 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 30 37 9.172446 $468.2600 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 7 9 1.675113 $85.5200 $51.0500
PSTH -97161 PT EVAL LOW COMPLEXITY 9 10 3.273592 $167.1200 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 7 8 1.943380 $99.2100 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 39 44 22.938038 $1170.9800 $51.0500
SPCH -92521 EVAL OF SPEECH FLUENCY 2 2 0.746575 $38.1100 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 7 7 3.428234 $175.0100 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 45 49 12.329755 $629.4400 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 22 24 7.806944 $398.5500 $51.0500
VISD -99202 VISION EVAL DIAG (SIMPLE) 1 1 0.246575 $8.8700 $35.9800
VISF -92499 VISION EVALUATION FUNCTIONAL 1 1 0.246575 $12.3300 $50.0100
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Subtotal (Total Children Is Unduplicated) 358 703 685.564304 $42441.5300 $61.9100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 61 90 40.742037 $203712.5000 $5000.0600
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 1.066667 $53.3400 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 2 2 0.715069 $164.4700 $230.0100
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 56 62 57.700882 $2885.0100 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 2 2 1.255556 $31.3900 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 401 574 1188.440838 $59422.0600 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 4 4 6.933333 $173.3300 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 145 183 343.283336 $17164.1800 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 4 4 7.450000 $186.2500 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 45 60 109.333334 $5466.6700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 300 378 673.200005 $33660.0300 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 3.216666 $80.4200 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 8 8 22.999997 $1686.3700 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 19 25 867.857139 $21696.4300 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 449 601 4223.450802 $211172.3500 $50.0000
INTR -T1013 INTERPRETER 30 49 120.166731 $6008.3400 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 473 933 4663.165616 $46631.6000 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 97 126 1056.026193 $75442.4000 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 4 4 36.500000 $2087.8000 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 99 134 998.899478 $71361.3200 $71.4400
PHY -97110HM PT SESSION BY PT ASST 1 1 12.857143 $734.9100 $57.1600
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 0.493151 $112.4500 $228.0200
SENS -V5140 BEHIND EAR BINAURAL HEARING AID
2 2 13.103718 $5975.2900 $456.0000
SENS -V5264 EARMOLD 5 5 15.023049 $270.4100 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 113 131 1132.033408 $80872.3400 $71.4400
TRAV -TRAVS Travel by mile 543 1476 359411.931206 $159938.3100 $0.4500
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Subtotal (Total Children Is Unduplicated) 595 4859 375007.845354 $1006989.9400 $2.6900
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Total 5563 375694.709658 $1049431.4700 $2.7900
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Number of Children (Unduplicated) With at Least One Authorization 599