Summary Report for FSPSAs Ending During the Report Period Center: 01
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: 10-01-19 and 12-31-19 Date of Report: 02-01-20 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 6262 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 51 51 115.311905 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 626 653 15707.907938 $581192.6900 $37.0000
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Subtotal (Total Children Is Unduplicated) 636 704 15823.219843 $581192.6900 $36.7300
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 19 19 11.265449 $546.3800 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 0.688889 $38.9200 $56.4900
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 1 1 0.450000 $4.4800 $9.9600
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 1 1 2.000000 $76.9400 $38.4700
AUDE -92585 AUD EVOKED RESPONSE (COMP) 12 12 9.705555 $823.4100 $84.8400
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 8 8 5.955556 $304.1500 $51.0700
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 0.411111 $9.2100 $22.4000
EXIT -EXIT EXIT ASSESSMENT 160 162 321.750000 $16087.5000 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 11 11 20.000000 $1500.0000 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 28 41 78.500000 $5887.5000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 10 10 19.500000 $1082.2500 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 143 143 262.000000 $19650.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 20 20 33.500000 $2512.5000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 27 27 46.000000 $3450.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 351 359 667.142857 $37026.4300 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 252 294 558.142857 $41860.7200 $75.0000
OCTH -97166 OT EVAL MODERATE COMPLEXITY 4 4 4.000000 $204.2000 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 4 4 5.000000 $255.2500 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 3 3 3.000000 $153.1500 $51.0500
SPCH -92521 EVAL OF SPEECH FLUENCY 3 3 3.000000 $153.1500 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 1 1 1.000000 $51.0500 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 1.087671 $55.5300 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 2 2 2.000000 $97.8800 $48.9400
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Subtotal (Total Children Is Unduplicated) 649 1132 2061.099945 $132181.6500 $64.1300
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 14 14 9.891932 $49459.5000 $4999.9800
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 1 1 0.261111 $13.0600 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 5 5 9.507936 $475.4000 $50.0000
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 0.450000 $32.2200 $71.6100
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 0.450000 $32.2200 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 23 23 24.344444 $5599.2100 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 228 243 366.493082 $18324.6700 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 7 7 7.750000 $193.7500 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 96 106 147.716666 $7385.8300 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 1.333333 $33.3300 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 27 27 33.888888 $1694.4400 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 58 62 72.190479 $3609.5400 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 66 68 85.466666 $4273.3300 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 1.066667 $26.6700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 693 737 4396.971405 $219848.5700 $50.0000
INTR -T1013 INTERPRETER 153 162 446.769045 $22338.4700 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 855 1256 5783.930149 $57839.3000 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 31 32 204.838093 $14633.6500 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 2 2 11.142857 $637.3700 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 64 68 340.501496 $24325.4300 $71.4400
PHY -97110HM PT SESSION BY PT ASST 2 2 8.142858 $465.4400 $57.1600
RSPT -RSPT RESPITE 1 1 1.000000 $0.0000 $0.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 65 70 398.188090 $28446.5600 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 7 7 46.285715 $642.4400 $13.8800
TRAV -TRAVS Travel by mile 1005 1529 6148.006340 $2735.8600 $0.4400
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Subtotal (Total Children Is Unduplicated) 1083 4426 18546.587252 $463066.2300 $24.9700
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Total 6262 36430.907040 $1176440.5700 $32.2900
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Number of Children (Unduplicated) With at Least One Authorization 1317