Summary Report for FSPSAs Initiated During the Report Period Center: 51
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 327 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 5 5 11.511111 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 5 5 11.511111 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
EXIT -EXIT EXIT ASSESSMENT 4 4 4.000000 $200.0000 $50.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 2 2 2.000000 $102.1000 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 6 6 5.116667 $261.2100 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 20 20 25.000000 $1276.2500 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 5 5 5.000000 $255.2500 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 6 6 6.000000 $306.3000 $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) 44 45 49.116667 $2498.9900 $50.8800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.000000 $5000.0000 $5000.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 2 2 3.700000 $185.0000 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 1.011111 $25.2800 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 2 2 2.700000 $135.0000 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 1 1 2.300000 $115.0000 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 1.011111 $25.2800 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 77 80 702.119046 $35105.9600 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 63 68 597.428572 $42680.2900 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 6 6 44.428571 $2541.3200 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 15 16 112.289287 $8021.9400 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 95 96 814.585714 $58193.9800 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 6.000000 $343.2000 $57.2000
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 12.285714 $170.5300 $13.8800
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Subtotal (Total Children Is Unduplicated) 207 277 2300.859126 $152542.7700 $66.3000
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Total 327 2361.486904 $155041.7500 $65.6500
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Number of Children (Unduplicated) With at Least One Authorization 226