Summary Report for FSPSAs Initiated During the Report Period Center: 55
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 2864 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 18 18 20.966667 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 44 44 8305.733333 $307312.1300 $37.0000
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Subtotal (Total Children Is Unduplicated) 59 62 8326.700000 $307312.1300 $36.9100
Screening, Eval, and Assessment, Class # 02
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.466667 $21.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.233333 $26.8300 $114.9800
EVAL -96111 DEVELOPMENTAL EVALUATION 35 42 37.125569 $1856.2900 $50.0000
EXIT -EXIT EXIT ASSESSMENT 35 35 58.795890 $2939.8000 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 10 10 20.000000 $1500.0000 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 9 9 16.005479 $1200.4100 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 3 3 6.000000 $450.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 4 4 6.005479 $333.3100 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 189 189 376.005479 $28200.4100 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 169 169 326.032874 $24452.4800 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 28 28 56.000000 $4200.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 65 66 114.049311 $6329.7500 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 57 57 110.010958 $8250.8300 $75.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 55 58 15.480164 $790.2900 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 18 19 7.905556 $403.5800 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 52 54 24.761111 $1264.0500 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 24 26 6.122227 $312.5600 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 4 4 1.300000 $66.3700 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 25 27 11.261113 $574.8900 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 1 1 0.177778 $9.0800 $51.0600
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 115 129 40.575403 $2071.4000 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 2 3 0.238889 $11.6900 $48.9400
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Subtotal (Total Children Is Unduplicated) 496 936 1236.553280 $85415.0100 $69.0800
EI Services, Class # 03
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 1 1 0.466667 $23.3400 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 6 8 5.088888 $254.4400 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 2 2 0.655556 $16.3900 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 202 219 126.288884 $6314.4200 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 186 197 186.576984 $4664.4200 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 128 227 181.222212 $9061.0600 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 75 120 148.044443 $3701.1100 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 32 59 44.511105 $2225.5300 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 15 26 29.101586 $727.5400 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 182 191 102.711111 $5135.5600 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 175 182 155.688888 $3892.2200 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 5 5 47.000000 $1175.0000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 237 250 1387.112737 $69355.5800 $50.0000
INTR -T1013 INTERPRETER 1 1 2.000000 $100.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 82 83 303.546039 $21685.3100 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 92 95 625.140488 $35758.0100 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 25 25 163.259526 $11663.2500 $71.4400
PHY -97110HM PT SESSION BY PT ASST 27 28 174.357144 $9966.2500 $57.1600
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 0.466667 $212.8200 $456.0300
SENS -V5264 EARMOLD 1 1 0.466667 $8.4000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 131 143 800.035729 $57154.4700 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 15.142858 $210.1800 $13.8800
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Subtotal (Total Children Is Unduplicated) 458 1866 4498.884179 $243305.2900 $54.0800
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Total 2864 14062.137459 $636032.4300 $45.2300
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Number of Children (Unduplicated) With at Least One Authorization 623