Summary Report for FSPSAs Ending During the Report Period Center: 53
This report shows the total number of units/fees for FSPSAs ending during the report period.
(i.e., end 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 ending 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 1101 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 0.733333 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 1 1 4.000000 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 29 29 54.522222 $2017.3200 $37.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 32 32 59.255555 $2017.3200 $34.0400
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 1 1 0.488889 $23.7100 $48.5000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 9 9 3.011112 $41.7700 $13.8700
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 15 15 5.922222 $140.3600 $23.7000
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.377778 $17.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.377778 $43.4500 $115.0100
EXIT -EXIT EXIT ASSESSMENT 1 1 2.000000 $100.0000 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 2 2 2.500000 $187.5000 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 0.833333 $62.5000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 1 1 1.666667 $125.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 1 1 2.000000 $111.0000 $55.5000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 29 33 19.177779 $852.2800 $44.4400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 1.488889 $7444.5000 $5000.0400
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 1 1 0.088889 $4.4500 $50.0100
AUD -92633 AUD REHAB POSTLING HEARING LOSS 2 2 2.000000 $143.2200 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 9 9 4.394445 $1010.7400 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 19 23 23.155556 $1157.7800 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 19 20 29.438889 $1471.9500 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 24 25 32.877778 $1643.8900 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 32 34 66.342064 $3317.1100 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 11 11 12.927777 $646.3900 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 4.888889 $122.2200 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 3 3 1.566667 $114.8700 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 15 18 27.453970 $686.3500 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 273 301 1347.104768 $67355.2900 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 356 492 1942.561907 $19425.6300 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 27 32 122.028568 $8717.7200 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 1 1 1.533333 $87.7000 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 29 30 178.528569 $12754.0700 $71.4400
PHY -97110HM PT SESSION BY PT ASST 2 2 5.361904 $306.4900 $57.1600
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 0.377778 $24.5600 $65.0000
SENS -V5264 EARMOLD 1 1 0.755556 $13.6000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 25 27 145.636507 $10404.2600 $71.4400
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 368 1036 3950.512703 $136852.7700 $34.6400
-------------------------------------------------------------------------------------------------------------------------------------
Total 1101 4028.946037 $139722.3700 $34.6800
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 373