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 643 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 11 14 14.421918 $721.1000 $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 2 2 4.000000 $300.0000 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 2 2 0.084932 $6.3700 $74.9700
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 6 6 4.015069 $222.8300 $55.5000
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
OCTH -97166 OT EVAL MODERATE COMPLEXITY 1 1 0.122222 $6.2400 $51.0400
OCTH -97167 OT EVAL HIGH COMPLEXITY 1 1 0.079452 $4.0600 $51.0800
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 4 4 0.810959 $41.4100 $51.0600
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Subtotal (Total Children Is Unduplicated) 28 39 25.570168 $1454.4100 $56.8800
EI Services, Class # 03
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 67 68 81.461504 $4073.0600 $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
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 14 15 101.857143 $5092.8600 $50.0000
INTR -T1013 INTERPRETER 8 9 59.285715 $2964.2900 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 1 1 6.571429 $469.4600 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 3 4 20.714286 $1479.8200 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 2 3 23.428571 $1673.7400 $71.4400
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Subtotal (Total Children Is Unduplicated) 246 591 945.943532 $48274.6200 $51.0300
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Total 643 983.839098 $49729.0200 $50.5500
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Number of Children (Unduplicated) With at Least One Authorization 270