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 3840 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 49 51 101.414288 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 17 17 495.857143 $18346.7100 $37.0000
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Subtotal (Total Children Is Unduplicated) 67 70 598.649209 $18397.6900 $30.7300
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 19 20 12.313013 $597.1800 $48.5000
EXIT -EXIT EXIT ASSESSMENT 206 209 410.750000 $20537.5000 $50.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 2 0.907143 $50.3400 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 2 2 4.000000 $300.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 11 11 19.500000 $1082.2500 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 8 9 15.000000 $1125.0000 $75.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
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Subtotal (Total Children Is Unduplicated) 239 255 464.470156 $23794.3700 $51.2300
EI Services, Class # 03
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 2 2 2.000000 $100.0000 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 231 249 375.871149 $18793.5600 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 7 8 7.316667 $182.9200 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 83 89 160.312700 $8015.6400 $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 42 43 72.074603 $3603.7300 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 2 2 47.500000 $1187.5000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 56 57 71.838889 $3591.9500 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 3.933334 $98.3400 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 21 24 138.628573 $6931.4400 $50.0000
INTR -T1013 INTERPRETER 111 130 365.311257 $18265.5700 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 916 1311 5768.495439 $57684.9300 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 1 1 4.466667 $319.1000 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 4 5 26.352382 $1882.6200 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 2 2 11.000000 $785.8400 $71.4400
TRAV -TRAVS Travel by mile 951 1563 6107.045797 $2717.6400 $0.4500
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Subtotal (Total Children Is Unduplicated) 971 3515 13191.097456 $125539.5100 $9.5200
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Total 3840 14254.216821 $167731.5600 $11.7700
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Number of Children (Unduplicated) With at Least One Authorization 994