Summary Report for FSPSAs Initiated During the Report Period Center: 55
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 1375 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 14 14 14.322221 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 14 14 14.322221 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
EVAL -96111 DEVELOPMENTAL EVALUATION 22 29 13.691169 $684.5600 $50.0000
EXIT -EXIT EXIT ASSESSMENT 28 29 43.070471 $2153.5200 $50.0000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 8 8 16.000000 $1200.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 7 7 14.000000 $1050.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 2 2 4.000000 $300.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 8 9 16.005479 $888.3100 $55.5000
OCTF -97168 OT RE-EVAL EST PLAN CARE 1 1 0.172222 $8.7900 $51.0400
OCTH -97166 OT EVAL MODERATE COMPLEXITY 1 1 0.172222 $8.7900 $51.0400
OCTH -97167 OT EVAL HIGH COMPLEXITY 2 2 0.288889 $14.7500 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 2 2 0.311111 $15.8800 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 3 3 0.455555 $23.2500 $51.0400
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Subtotal (Total Children Is Unduplicated) 71 93 108.167118 $6347.8500 $58.6900
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 9 10 7.150001 $357.5100 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 216 227 160.333330 $8016.6500 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 196 204 227.172220 $5679.3000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 113 204 119.466663 $5973.3200 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 72 126 128.822235 $3220.5900 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 33 58 34.461109 $1723.0500 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 24 42 46.311115 $1157.7900 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 185 188 127.483332 $6374.1600 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 178 183 188.338891 $4708.4800 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 11 11 61.857144 $3092.8500 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 5 5 26.142857 $1867.6500 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 3 3 13.285715 $759.9400 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 1 1 1.339286 $95.6800 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 6 6 27.571430 $1969.6900 $71.4400
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Subtotal (Total Children Is Unduplicated) 317 1268 1169.735328 $44996.6300 $38.4700
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Total 1375 1292.224667 $51344.4800 $39.7300
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Number of Children (Unduplicated) With at Least One Authorization 371