Summary Report for FSPSAs Initiated During the Report Period Center: 01
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: 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 6201 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 1 1 0.800000 $29.6000 $37.0000
SCONLY-SCONLY *SERVICE COORDINATION ONLY 55 55 224.269363 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 618 620 17440.370632 $645293.7500 $37.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 634 676 17665.439995 $645323.3500 $36.5300
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 17 18 13.994520 $678.7300 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.000000 $56.4900 $56.4900
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 1 1 2.000000 $76.9400 $38.4700
AUDE -92585 AUD EVOKED RESPONSE (COMP) 8 8 8.000000 $678.7200 $84.8400
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 2 2 2.000000 $102.1400 $51.0700
EVAL -96111 DEVELOPMENTAL EVALUATION 1 1 1.000000 $50.0000 $50.0000
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 143 143 261.500000 $19612.5000 $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 26 26 44.000000 $3300.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 353 361 670.642857 $37220.6800 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 254 296 561.642857 $42123.2200 $75.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 3 3 2.147945 $109.6500 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 11 11 17.285714 $882.4400 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 2 2 1.147945 $58.6000 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 5 5 7.000000 $357.3500 $51.0500
SPCH -92521 EVAL OF SPEECH FLUENCY 6 6 6.000000 $306.3000 $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 8 9 8.087671 $412.8800 $51.0500
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 646 1141 2086.699509 $133498.4800 $63.9800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 10 11 11.928158 $59641.0000 $5000.0200
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 1 1 0.227778 $11.3900 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 5 5 4.300000 $215.0000 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 6 6 8.000000 $1840.0000 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 229 243 270.869300 $13543.4800 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 9 9 29.535714 $738.3900 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 89 102 180.247615 $9012.3600 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 2.533333 $63.3300 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 34 35 56.116665 $2805.8300 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 48 49 82.049998 $4102.4900 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 76 79 136.438887 $6821.9400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 2.533333 $63.3300 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 704 740 4977.804776 $248890.1800 $50.0000
INTR -T1013 INTERPRETER 135 148 350.283333 $17514.1700 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 902 1249 6537.260439 $65372.5800 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 29 30 196.038095 $14004.9600 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 4 4 34.285714 $1961.1400 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 48 52 353.057142 $25222.4200 $71.4400
PHY -97110HM PT SESSION BY PT ASST 9 9 47.214286 $2698.7600 $57.1600
RSPT -RSPT RESPITE 1 1 1.000000 $0.0000 $0.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 73 74 532.387300 $38033.7300 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 9 9 65.000000 $902.2000 $13.8800
TRAV -TRAVS Travel by mile 934 1526 6883.208060 $3063.0300 $0.4400
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 979 4384 20762.319926 $516521.6900 $24.8800
-------------------------------------------------------------------------------------------------------------------------------------
Total 6201 40514.459430 $1295343.5300 $31.9700
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 1047