Summary Report for FSPSAs Initiated During the Report Period Statewide
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 15218 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 252 257 422.119054 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 4 4 8.988888 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 19 19 523.857143 $19382.7100 $37.0000
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Subtotal (Total Children Is Unduplicated) 276 282 956.342863 $19433.6900 $20.3200
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 100 112 75.707304 $3671.8000 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 0.472222 $26.6700 $56.4900
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 99 99 99.000000 $2325.5100 $23.4900
AUDE -92585 AUD EVOKED RESPONSE (COMP) 1 1 0.166667 $14.1400 $84.8600
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.000000 $45.0000 $45.0000
EVAL -96111 DEVELOPMENTAL EVALUATION 34 41 35.870013 $1793.5100 $50.0000
EXIT -EXIT EXIT ASSESSMENT 474 490 818.724158 $40936.2200 $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 4 5 2.023582 $112.3000 $55.5000
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 1 1 1.500000 $83.2500 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 13 13 24.004110 $1800.3100 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 12 12 18.016437 $1351.2400 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 4 4 2.010959 $150.8200 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 30 30 44.591781 $2474.8400 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 13 14 23.071233 $1730.3400 $75.0000
NUTR -97802 NUTRITIONAL EVAL, INITIAL 3 3 4.299999 $215.0000 $50.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 1 1 0.305556 $15.6000 $51.0600
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 2 2 1.138889 $58.1400 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 17 17 18.705556 $954.9200 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 2 2 2.000000 $102.1000 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 13 13 5.969786 $304.7600 $51.0500
SCREEN-T1023 SCREENING 1 1 1.000000 $50.0000 $50.0000
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 17 18 15.609513 $796.8600 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 1.000000 $48.9400 $48.9400
VISF -92499 VISION EVALUATION FUNCTIONAL 1 1 0.505556 $25.2800 $50.0000
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Subtotal (Total Children Is Unduplicated) 797 886 1197.696061 $59138.8000 $49.3800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 16 20 26.305556 $131528.0000 $5000.0100
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 3 3 0.748859 $37.4400 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 5 5 4.371233 $218.5600 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 1.000000 $230.0000 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 734 842 793.912936 $39695.7700 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 57 60 40.645740 $1016.1500 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1385 1554 2157.817203 $107890.8000 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 208 219 231.557935 $5788.9400 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 790 934 1050.090385 $52504.4100 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 82 128 157.151586 $3928.7900 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 459 514 622.979359 $31148.9500 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 21 32 84.768252 $2119.2000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1292 1353 1364.966621 $68248.3100 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 208 215 200.683332 $5017.0800 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 5 5 31.000001 $775.0000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 215 236 1531.088899 $76554.4500 $50.0000
INTR -T1013 INTERPRETER 167 207 717.620195 $35881.0200 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 3646 5034 24436.577465 $244365.6800 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 17 17 114.712700 $8195.0700 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 14 14 89.028574 $5092.4200 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 51 56 274.835720 $19634.2400 $71.4400
PHY -97110HM PT SESSION BY PT ASST 2 2 5.285715 $302.1300 $57.1600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 60 62 365.708440 $26126.1900 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 0.928571 $12.8900 $13.8800
TRAV -TRAVS Travel by mile 1311 2536 148818.368624 $66224.1800 $0.4500
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Subtotal (Total Children Is Unduplicated) 5420 14050 183122.153901 $932535.6300 $5.0900
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Total 15218 185276.192825 $1011108.1200 $5.4600
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Number of Children (Unduplicated) With at Least One Authorization 5912