Summary Report for FSPSAs Ending During the Report Period Center: 05
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 1424 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 15 16 27.720635 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 1.600000 $59.2000 $37.0000
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Subtotal (Total Children Is Unduplicated) 16 17 29.320635 $59.2000 $2.0200
Screening, Eval, and Assessment, Class # 02
EXIT -EXIT EXIT ASSESSMENT 24 33 44.696283 $2234.8100 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 4 6 7.005479 $525.4100 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 10 10 1.043838 $78.2600 $74.9800
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 0.002740 $0.2000 $73.9100
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 4 4 0.015069 $1.1300 $74.6600
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 12 12 1.224660 $91.8200 $74.9800
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 34 34 16.149320 $896.2500 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 39 39 0.112338 $8.3200 $74.0400
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 3 3 0.008220 $0.6100 $73.9100
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 66 66 0.253437 $18.9300 $74.6900
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 55 55 0.161658 $8.8600 $54.8100
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 26 27 0.073980 $5.4700 $73.9100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 2 2 1.244444 $63.5300 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 32 32 28.422451 $1450.9700 $51.0500
PSTH -97161 PT EVAL LOW COMPLEXITY 3 3 3.000000 $153.1500 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 28 29 22.320963 $1139.4900 $51.0500
SPCH -92521 EVAL OF SPEECH FLUENCY 1 1 9.142857 $466.7500 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 2 2 2.000000 $102.1000 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 62 63 28.610635 $1460.5700 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 1 1 0.244444 $12.4800 $51.0400
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 5 5 13.785714 $674.6800 $48.9400
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Subtotal (Total Children Is Unduplicated) 298 428 179.518530 $9393.7700 $52.3300
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 10 10 9.200000 $46000.0000 $5000.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 10 11 7.374887 $368.7500 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 185 197 250.896728 $12544.8200 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 5 5 12.209524 $305.2400 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 60 62 68.496030 $3424.7900 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 78 84 80.433778 $4021.6800 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 3 3 4.400000 $110.0000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 149 161 209.134527 $10456.7300 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 9 9 14.200000 $355.0000 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 9 11 50.714284 $1267.8600 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 184 195 1105.780945 $55289.0800 $50.0000
INTR -T1013 INTERPRETER 9 10 39.261904 $1963.0900 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 41 42 269.519042 $19254.4500 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 5 5 46.000000 $2631.2100 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 53 53 278.676187 $19908.6400 $71.4400
PHY -97110HM PT SESSION BY PT ASST 5 5 22.285714 $1273.8600 $57.1600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 106 111 665.574811 $47548.6700 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 5 5 41.000000 $569.0800 $13.8800
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Subtotal (Total Children Is Unduplicated) 271 979 3175.158361 $227292.9300 $71.5800
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Total 1424 3383.997526 $236745.9000 $69.9600
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Number of Children (Unduplicated) With at Least One Authorization 441