Summary Report for FSPSAs Initiated During the Report Period Center: 57
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 1763 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 5 5 15.223810 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 2 2 0.922222 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 2 2 13.049207 $482.8200 $37.0000
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Subtotal (Total Children Is Unduplicated) 8 9 29.195239 $482.8200 $16.5400
Screening, Eval, and Assessment, Class # 02
OCTF -97168 OT RE-EVAL EST PLAN CARE 1 1 0.388889 $19.8500 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 31 31 19.438890 $992.3600 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 2 2 0.738889 $37.7200 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 9 9 4.616666 $235.6800 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 25 25 15.588890 $795.8200 $51.0500
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Subtotal (Total Children Is Unduplicated) 40 68 40.772224 $2081.4300 $51.0500
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1 4 0.022224 $1.1200 $50.4000
CONOF -CONOF CONSULT, OT, FACE TO FACE 106 106 45.077776 $2253.8800 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 14 14 9.300792 $465.0400 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 226 232 102.533333 $5126.6700 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 90 111 509.142855 $12728.6200 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 465 482 3172.982582 $158649.0600 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 464 481 3195.574645 $31955.7300 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 83 102 294.948030 $21071.0100 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 3 3 5.214286 $298.2500 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 39 46 145.428580 $10389.3800 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 82 99 257.357158 $18385.5000 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 6 6 15.285715 $212.1700 $13.8800
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Subtotal (Total Children Is Unduplicated) 545 1686 7752.867976 $261536.4200 $33.7300
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Total 1763 7822.835439 $264100.6700 $33.7600
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Number of Children (Unduplicated) With at Least One Authorization 554