Summary Report for FSPSAs Initiated During the Report Period Center: 05
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 634 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 9 9 10.338096 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 9 9 10.338096 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
EXIT -EXIT EXIT ASSESSMENT 33 43 46.798435 $2339.9200 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 1 1 0.001370 $0.1100 $76.6400
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 0.001370 $0.1100 $76.6400
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 3 3 1.116439 $61.9600 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 1 1 0.004110 $0.3100 $74.8200
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 1 1 0.005479 $0.4100 $75.2900
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 3 3 0.010959 $0.8200 $74.6000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 3 3 0.009590 $0.5300 $54.9700
OCTH -97167 OT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 1 1 0.038356 $1.9600 $51.1100
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Subtotal (Total Children Is Unduplicated) 44 58 48.986108 $2457.1700 $50.1600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.000000 $5000.0000 $5000.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 15 16 6.278388 $313.9100 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 1.233333 $30.8300 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 192 210 234.304155 $11715.1900 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 5 5 17.514286 $437.8600 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 72 78 86.448338 $4322.4000 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 75 77 77.638886 $3881.9300 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 2 2 4.333333 $108.3300 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 136 148 139.979719 $6998.9600 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 5 5 7.000000 $175.0000 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 6.571429 $164.2900 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 13 13 95.233333 $4761.6700 $50.0000
INTR -T1013 INTERPRETER 6 6 49.509524 $2475.4800 $50.0000
PHY -97110 PT SESSION BY LICENSED PT 2 2 12.357143 $882.7900 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 2 2 18.857143 $1347.1500 $71.4400
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Subtotal (Total Children Is Unduplicated) 237 567 758.259010 $42615.7700 $56.2000
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Total 634 817.583214 $45072.9400 $55.1300
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Number of Children (Unduplicated) With at Least One Authorization 266