Summary Report for FSPSAs Initiated During the Report Period Center: 09
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 245 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 17 17 26.030160 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 17 17 26.030160 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
NUTR -97802 NUTRITIONAL EVAL, INITIAL 3 4 20.000000 $1000.0000 $50.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 4 4 8.509524 $425.4800 $50.0000
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Subtotal (Total Children Is Unduplicated) 7 8 28.509524 $1425.4800 $50.0000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 2 2.000000 $10000.0000 $5000.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 58 77 97.747810 $4887.4000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 19 19 11.704111 $292.6000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 28 29 34.066666 $1703.3300 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 18 19 21.233333 $1061.6700 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 19 21 22.905555 $1145.2800 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 2 2 2.000000 $50.0000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 24 24 30.477778 $1523.8900 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 3.000000 $75.0000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 12 13 88.000000 $4400.0100 $50.0000
INTR -T1013 INTERPRETER 1 1 1.000000 $50.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 2 2 16.428571 $1173.6600 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 1 1 12.285714 $877.6900 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 5 7 61.428571 $4388.4600 $71.4400
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Subtotal (Total Children Is Unduplicated) 120 220 404.278109 $31628.9700 $78.2400
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Total 245 458.817793 $33054.4500 $72.0400
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Number of Children (Unduplicated) With at Least One Authorization 142