Summary Report for FSPSAs Ending During the Report Period Center: 51
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 337 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 8 8 10.333334 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 8 8 10.333334 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
EXIT -EXIT EXIT ASSESSMENT 4 4 4.000000 $200.0000 $50.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 1 1 1.000000 $55.5000 $55.5000
OCTH -97165 OT EVAL LOW COMPLEXITY 3 3 3.000000 $153.1500 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 4 4 4.000000 $204.2000 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 20 20 23.142857 $1181.4500 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 7 7 7.000000 $357.3500 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 7 7 7.000000 $357.3500 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 2 2 2.000000 $97.8800 $48.9400
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Subtotal (Total Children Is Unduplicated) 47 48 51.142857 $2606.8800 $50.9700
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.000000 $5000.0000 $5000.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 2 2 1.955556 $97.7800 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 5 5 4.599999 $230.0000 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 3 3 5.011111 $125.2800 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 1 1 1.266667 $63.3400 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 3 3 3.795237 $189.7600 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 4.100000 $102.5000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 77 79 520.090477 $26004.5300 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 54 60 422.285714 $30168.0800 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 3 5 29.285714 $1675.1400 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 16 18 184.676190 $13193.2600 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 94 98 664.461902 $47469.1700 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 3 3 29.428571 $408.4700 $13.8800
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Subtotal (Total Children Is Unduplicated) 192 281 1871.957138 $124727.3000 $66.6300
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Total 337 1933.433329 $127334.1700 $65.8600
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Number of Children (Unduplicated) With at Least One Authorization 236