Summary Report for FSPSAs Initiated During the Report Period Center: 01
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: 07-01-19 and 09-30-19 Date of Report: 11-04-19 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 6383 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
CASE -CASE NON-TCM CASE MANAGEMENT 2 2 1.377778 $50.9800 $37.0000
SCONLY-SCONLY *SERVICE COORDINATION ONLY 58 60 104.469843 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 609 625 15447.128562 $571543.5200 $37.0000
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Subtotal (Total Children Is Unduplicated) 618 687 15552.976183 $571594.5000 $36.7500
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 19 20 12.313013 $597.1800 $48.5000
AUDE -92585 AUD EVOKED RESPONSE (COMP) 3 3 4.000000 $339.3600 $84.8400
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 1 1 1.000000 $51.0700 $51.0700
EXIT -EXIT EXIT ASSESSMENT 209 212 416.750000 $20837.5000 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 3 3 5.000000 $375.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 13 13 23.000000 $1725.0000 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 3 3 5.000000 $375.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 28 45 58.566666 $4392.5000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 14 16 23.957143 $1329.6200 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 137 138 226.500000 $16987.5000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 15 15 27.000000 $2025.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 25 25 44.500000 $3337.5000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 323 332 582.500000 $32328.7500 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 256 321 543.500000 $40762.5000 $75.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 1 1 1.000000 $51.0500 $51.0500
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 5 5 3.175342 $162.1000 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 2 2 2.000000 $102.1000 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 4 5 5.000000 $255.2500 $51.0500
SPCH -92521 EVAL OF SPEECH FLUENCY 3 3 4.000000 $204.2000 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 1 1 1.000000 $51.0500 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 5 5 3.318199 $169.4000 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 2 2 4.571429 $223.7200 $48.9400
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Subtotal (Total Children Is Unduplicated) 684 1172 1998.651792 $126733.4000 $63.4100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 19 20 18.437518 $92187.0000 $4999.9700
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 3 3 3.000000 $150.0000 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 0.766667 $54.9000 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 8 8 12.211111 $2808.5500 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 237 257 385.014006 $19250.7100 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 7 8 7.316667 $182.9200 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 85 91 163.112700 $8155.6400 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 4 4 2.750000 $68.7500 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 22 22 26.199999 $1310.0000 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 44 45 76.874603 $3843.7300 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 2 2 47.500000 $1187.5000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 58 59 75.505556 $3775.2800 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 3.933334 $98.3400 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 714 762 4371.461976 $218573.0600 $50.0000
INTR -T1013 INTERPRETER 131 153 401.454114 $20072.7200 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 917 1312 5774.495439 $57744.9300 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 31 32 124.119052 $8867.0500 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 3 4 39.000000 $2230.8000 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 70 75 432.304770 $30883.8100 $71.4400
PHY -97110HM PT SESSION BY PT ASST 7 7 25.336508 $1448.2300 $57.1600
SENS -V5264 EARMOLD 2 2 0.144292 $2.6000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 70 82 449.604768 $32119.7900 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 8 8 28.142858 $390.6200 $13.8800
TRAV -TRAVS Travel by mile 952 1564 6113.045797 $2720.3100 $0.4500
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Subtotal (Total Children Is Unduplicated) 984 4524 18581.731735 $508127.2300 $27.3500
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Total 6383 36133.359710 $1206455.1300 $33.3900
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Number of Children (Unduplicated) With at Least One Authorization 1064