Summary Report for FSPSAs Ending During the Report Period Center: 57
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 1612 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 2 2 6.100000 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 1 1 0.066667 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 5 5 46.142857 $1707.2800 $37.0000
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Subtotal (Total Children Is Unduplicated) 8 8 52.309524 $1707.2800 $32.6400
Screening, Eval, and Assessment, Class # 02
OCTF -97168 OT RE-EVAL EST PLAN CARE 2 2 0.222222 $11.3400 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 23 24 11.332539 $578.5200 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 2 2 0.316667 $16.1700 $51.0600
PSTH -97163 PT EVAL HIGH COMPLEXITY 12 12 3.272222 $167.0500 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 22 23 11.554762 $589.8700 $51.0500
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Subtotal (Total Children Is Unduplicated) 34 63 26.698412 $1362.9400 $51.0500
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1 1 0.044444 $2.2200 $49.9500
CONOF -CONOF CONSULT, OT, FACE TO FACE 109 113 51.220631 $2561.0200 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 10 11 3.994444 $199.7200 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 238 245 102.593652 $5129.6900 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 0.888889 $22.2200 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 60 64 394.214281 $9855.3600 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 456 472 3009.206315 $150460.4400 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 460 483 3016.645205 $30166.4800 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 54 57 193.128570 $13797.1400 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 1 1 4.071429 $232.8800 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 28 29 121.571428 $8685.0800 $71.4400
PHY -97110HM PT SESSION BY PT ASST 1 1 9.428571 $538.9400 $57.1600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 53 56 201.142856 $14369.6800 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 10.714285 $148.7100 $13.8800
TRAV -TRAVS Travel by mile 4 4 74.857143 $33.3100 $0.4500
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Subtotal (Total Children Is Unduplicated) 526 1541 7193.722143 $236202.8800 $32.8300
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Total 1612 7272.730079 $239273.1100 $32.9000
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Number of Children (Unduplicated) With at Least One Authorization 536