Summary Report for FSPSAs Initiated During the Report Period Center: 57
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: 02-06-19 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1060 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 0.822222 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 1.000000 $37.0000 $37.0000
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Subtotal (Total Children Is Unduplicated) 3 3 1.822222 $37.0000 $20.3000
Screening, Eval, and Assessment, Class # 02
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 7 7 11.285714 $626.3600 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 7 7 11.285714 $846.4300 $75.0000
OCTH -97167 OT EVAL HIGH COMPLEXITY 29 30 16.842067 $859.8000 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 21 21 15.886509 $811.0100 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 22 22 14.264289 $728.2100 $51.0500
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Subtotal (Total Children Is Unduplicated) 48 87 69.564293 $3871.8100 $55.6600
EI Services, Class # 03
CONOF -CONOF CONSULT, OT, FACE TO FACE 63 65 36.197616 $1809.8600 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 5 5 2.572223 $128.6200 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 121 125 82.472221 $4123.6100 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 1.661111 $41.5300 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 39 39 265.000005 $6625.0100 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 285 295 1959.138120 $97956.9100 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 285 321 1949.973041 $19499.7300 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 37 38 183.714288 $13124.5100 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 6 6 14.571429 $833.4700 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 18 18 123.285716 $8807.5000 $71.4400
PHY -97110HM PT SESSION BY PT ASST 4 4 6.928572 $396.0300 $57.1600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 27 27 131.285715 $9379.0200 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 2 2.714286 $155.2500 $57.2000
SPL -92508 GROUP SPL SESSION PER CHILD 7 7 30.071429 $417.3900 $13.8800
TRAV -TRAVS Travel by mile 7 15 8456.285713 $3763.0500 $0.4500
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Subtotal (Total Children Is Unduplicated) 320 970 13245.871485 $167061.4600 $12.6100
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Total 1060 13317.258000 $170970.2700 $12.8400
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Number of Children (Unduplicated) With at Least One Authorization 325