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
Eligibility Filter: Program Patients
With the filters selected there were 1862 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 15 15 14.466665 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 6 6 1350.000000 $49950.0000 $37.0000
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Subtotal (Total Children Is Unduplicated) 21 21 1364.466665 $49950.0000 $36.6100
Screening, Eval, and Assessment, Class # 02
EVAL -96111 DEVELOPMENTAL EVALUATION 26 34 16.135613 $806.7800 $50.0000
EXIT -EXIT EXIT ASSESSMENT 40 44 58.826026 $2941.3000 $50.0000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 23 23 42.010958 $3150.8300 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 21 21 40.005479 $3000.4100 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 4 4 8.000000 $600.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 21 22 36.021916 $1999.2200 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 1 1 2.000000 $150.0000 $75.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 5 5 0.777778 $39.7100 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 2 2 0.350000 $17.8700 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 6 6 2.272222 $116.0000 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 4 4 0.588889 $30.0600 $51.0500
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 0.172222 $8.7900 $51.0400
PSTH -97163 PT EVAL HIGH COMPLEXITY 3 3 0.611111 $31.2000 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 11 11 2.138888 $109.1900 $51.0500
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Subtotal (Total Children Is Unduplicated) 125 181 209.911102 $13001.3400 $61.9400
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 10 12 7.161113 $358.0700 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 2 2 0.505555 $12.6400 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 262 277 196.177771 $9808.8600 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 246 257 282.438884 $7060.9600 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 144 257 150.555552 $7527.7600 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 88 152 150.816680 $3770.4500 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 38 67 43.511106 $2175.5300 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 27 47 57.927780 $1448.2000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 229 233 158.283329 $7914.1500 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 225 232 234.211111 $5855.2800 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 3 3 14.571428 $364.2900 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 67 67 470.071428 $23503.5800 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 17 17 96.428572 $6888.8700 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 14 14 86.428571 $4943.7100 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 4 6 23.339286 $1667.3700 $71.4400
PHY -97110HM PT SESSION BY PT ASST 2 2 19.142857 $1094.2100 $57.1600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 15 15 95.285716 $6807.2000 $71.4400
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Subtotal (Total Children Is Unduplicated) 419 1660 2086.856739 $91201.1000 $43.7000
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Total 1862 3661.234506 $154152.4400 $42.1000
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Number of Children (Unduplicated) With at Least One Authorization 503