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 626 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
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Subtotal (Total Children Is Unduplicated) 15 16 27.720635 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
EXIT -EXIT EXIT ASSESSMENT 22 31 40.696283 $2034.8100 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 2 2 2.005479 $150.4100 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 1 1 0.002740 $0.2000 $73.9100
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 5 5 0.072603 $4.0200 $55.4200
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 1 1 0.005479 $0.4100 $75.2900
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 2 2 0.008219 $0.6200 $74.8300
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 3 3 0.013699 $0.7600 $55.5100
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 1 1 0.002740 $0.2000 $73.9100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.030137 $1.5400 $50.9900
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Subtotal (Total Children Is Unduplicated) 34 47 42.837379 $2192.9800 $51.1900
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 10 11 7.374887 $368.7500 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 184 196 250.396728 $12519.8200 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 5 5 12.209524 $305.2400 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 60 61 67.462697 $3373.1300 $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 3 4 20.428570 $510.7200 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 9 9 50.928570 $2546.4400 $50.0000
INTR -T1013 INTERPRETER 9 9 35.404761 $1770.2400 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 2 2 10.285714 $734.8100 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 1 1 23.142857 $1323.7700 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 4 4 26.000000 $1857.4300 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 4 4 22.571428 $1612.5000 $71.4400
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Subtotal (Total Children Is Unduplicated) 238 563 834.374041 $41866.2500 $50.1800
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Total 626 904.932055 $44059.2200 $48.6900
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Number of Children (Unduplicated) With at Least One Authorization 262