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: 10-01-18 and 12-31-18 Date of Report: 02-05-19 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 2099 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 2 2 4.666666 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 2 2 4.666666 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 22 22 6.804720 $330.0300 $48.5000
EVAL -96111 DEVELOPMENTAL EVALUATION 1 1 0.022222 $1.1100 $49.9500
EXIT -EXIT EXIT ASSESSMENT 60 61 59.783563 $2989.1800 $50.0000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 3 3 4.005479 $300.4100 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 7 7 11.505479 $638.5600 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 4 4 7.500000 $562.5000 $75.0000
OCTH -97166 OT EVAL MODERATE COMPLEXITY 1 1 0.305556 $15.6000 $51.0600
PSTH -97162 PT EVAL MODERATE COMPLEXITY 1 1 0.202740 $10.3500 $51.0400
PSTH -97163 PT EVAL HIGH COMPLEXITY 2 2 1.394444 $71.1800 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 0.005480 $0.2800 $50.2900
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Subtotal (Total Children Is Unduplicated) 93 104 91.529683 $4919.2000 $53.7400
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 48 51 45.373519 $2268.6700 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 3 3 1.538851 $38.4700 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 229 245 421.989826 $21099.4900 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 2.366667 $59.1700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 107 109 174.947617 $8747.3800 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 2 2 5.300000 $132.5000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 17 17 33.600001 $1680.0100 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 177 178 309.566666 $15478.3300 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 3.166667 $79.1700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 6 6 58.214287 $2910.7100 $50.0000
INTR -T1013 INTERPRETER 20 29 76.823875 $3841.2000 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 272 469 2153.893781 $21538.9100 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 3 3 25.928572 $1852.3300 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 5 5 48.814286 $3487.2900 $71.4400
SENS -V5264 EARMOLD 1 1 0.002740 $0.0500 $17.7400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 3 3 20.285715 $1449.2100 $71.4400
TRAV -TRAVS Travel by mile 330 868 171795.360208 $76448.9400 $0.4500
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Subtotal (Total Children Is Unduplicated) 339 1993 175177.173278 $161111.8000 $0.9200
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Total 2099 175273.369627 $166031.0000 $0.9500
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Number of Children (Unduplicated) With at Least One Authorization 369