Summary Report for FSPSAs Initiated During the Report Period Center: 05
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 1518 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 13 13 12.325398 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 13 13 12.325398 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
EXIT -EXIT EXIT ASSESSMENT 13 16 18.421918 $921.1000 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 1 1 0.005479 $0.4100 $75.2900
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 20 20 20.043838 $1503.2600 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 2 2 2.002740 $150.2000 $75.0000
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 14 14 4.387370 $329.0300 $74.9900
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 38 38 25.818880 $1432.9100 $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 56 56 0.243850 $13.4200 $55.0500
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 26 27 0.073980 $5.4700 $73.9100
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 10 10 6.757305 $344.9600 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 42 42 18.706544 $954.9600 $51.0500
PSTH -97161 PT EVAL LOW COMPLEXITY 3 3 3.000000 $153.1500 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 4 4 3.300000 $168.4700 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 35 36 20.403122 $1041.5800 $51.0500
SPCH -92521 EVAL OF SPEECH FLUENCY 1 1 1.011111 $51.6200 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 4 4 3.250000 $165.9100 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 84 86 44.287903 $2260.9200 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 3 3 2.266667 $115.7200 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 11 11 8.856468 $433.4300 $48.9400
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Subtotal (Total Children Is Unduplicated) 264 487 184.226239 $10126.5300 $54.9700
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 9 9 9.000000 $45000.0000 $5000.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 18 19 54.354251 $2717.7100 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 198 206 251.232143 $12561.6200 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 0.461111 $11.5300 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 68 69 82.494837 $4124.7300 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 2.933333 $73.3300 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 87 91 155.574998 $7778.7400 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 159 172 187.069048 $9353.4600 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 1.000000 $25.0000 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 8 10 91.571428 $2289.2900 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 209 214 1429.928570 $71496.4000 $50.0000
INTR -T1013 INTERPRETER 9 10 63.142858 $3157.1400 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 43 44 282.803967 $20203.5100 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 2 2 2.623810 $150.0800 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 58 59 381.090477 $27225.0700 $71.4400
PHY -97110HM PT SESSION BY PT ASST 10 10 62.500000 $3572.4900 $57.1600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 85 88 541.127777 $38658.1800 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 12 12 75.928573 $1053.8900 $13.8800
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Subtotal (Total Children Is Unduplicated) 304 1018 3674.837181 $249452.1700 $67.8800
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Total 1518 3871.388818 $259578.7000 $67.0500
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Number of Children (Unduplicated) With at Least One Authorization 386