Summary Report for FSPSAs Ending During the Report Period Center: 02
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 3108 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 0.811111 $30.0100 $37.0000
SCONLY-SCONLY *SERVICE COORDINATION ONLY 3 3 1.939682 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 0.166667 $6.1700 $37.0100
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Subtotal (Total Children Is Unduplicated) 5 5 2.917460 $36.1800 $12.4000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 22 23 11.642085 $564.6400 $48.5000
BEHV -H2014BA BEHAVIOR ANALYSIS-ASSOCIATE 1 1 3.285714 $160.2100 $48.7600
EXIT -EXIT EXIT ASSESSMENT 58 58 63.797259 $3189.8700 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 3 3 4.005479 $300.4100 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 2 2 4.000000 $300.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 3 3 4.005479 $222.3100 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 95 95 167.552052 $12566.4200 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 39 39 59.049311 $4428.7100 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 143 143 243.392556 $13508.3100 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 45 45 87.505479 $6562.9100 $75.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 2 2 0.122222 $6.2400 $51.0400
OCTH -97166 OT EVAL MODERATE COMPLEXITY 3 3 0.339726 $17.3500 $51.0600
OCTH -97167 OT EVAL HIGH COMPLEXITY 17 17 8.617428 $439.9100 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 6 6 0.881812 $45.0200 $51.0600
PSTH -97161 PT EVAL LOW COMPLEXITY 3 3 0.300000 $15.3200 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 3 3 2.043836 $104.3400 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 13 13 1.716667 $87.6400 $51.0500
SPCH -92521 EVAL OF SPEECH FLUENCY 1 1 1.000000 $51.0500 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 17 17 21.914590 $1118.7400 $51.0500
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Subtotal (Total Children Is Unduplicated) 275 477 685.171695 $43689.3700 $63.7600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 30 32 17.367732 $86838.0000 $4999.9600
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 55 59 55.055005 $2752.7300 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 2 2 2.700000 $67.5000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 242 269 452.569406 $22628.4700 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 5 5 9.933333 $248.3300 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 124 129 198.809525 $9940.4800 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 2 2 4.333333 $108.3300 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 19 19 23.133332 $1156.6600 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 205 212 317.890477 $15894.5300 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 5 5 10.466667 $261.6700 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 1 1 3.285714 $240.9100 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 12 12 1305.714287 $32642.8500 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 254 271 1648.561898 $82428.1300 $50.0000
INTR -T1013 INTERPRETER 24 42 63.758806 $3187.9400 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 305 521 1937.498174 $19374.9900 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 39 40 271.142859 $19370.4400 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 2 2 8.000000 $457.6000 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 38 38 232.142861 $16584.2800 $71.4400
PHY -97110HM PT SESSION BY PT ASST 1 1 1.428571 $81.6600 $57.1600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 32 32 222.310176 $15881.8300 $71.4400
TRAV -TRAVS Travel by mile 419 932 144532.846600 $64317.1200 $0.4500
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Subtotal (Total Children Is Unduplicated) 447 2626 151318.948756 $394464.4300 $2.6100
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Total 3108 152007.037911 $438189.9800 $2.8800
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Number of Children (Unduplicated) With at Least One Authorization 463