Summary Report for FSPSAs Initiated During the Report Period Center: 01
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: 01-01-20 and 03-31-20 Date of Report: 05-15-20 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 5531 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
CASE -CASE NON-TCM CASE MANAGEMENT 1 1 0.833333 $30.8300 $37.0000
SCONLY-SCONLY *SERVICE COORDINATION ONLY 49 49 158.952380 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 59 59 1948.423807 $72091.6800 $37.0000
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Subtotal (Total Children Is Unduplicated) 106 109 2108.209520 $72122.5200 $34.2100
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 19 21 19.240563 $933.1600 $48.5000
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 1 1 2.000000 $76.9400 $38.4700
AUDE -92585 AUD EVOKED RESPONSE (COMP) 7 8 7.322222 $621.2200 $84.8400
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 3 3 3.000000 $153.2100 $51.0700
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 1.000000 $115.0000 $115.0000
EXIT -EXIT EXIT ASSESSMENT 170 172 343.000000 $17150.0000 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 1 1 1.500000 $112.5000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 12 12 22.000000 $1650.0000 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 1.500000 $112.5000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 18 27 50.000000 $3750.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 13 21 39.000000 $2164.5000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 98 98 177.000000 $13275.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 16 16 26.500000 $1987.5000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 9 9 16.000000 $1200.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 240 241 434.500000 $24114.7500 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 201 239 428.500000 $32137.5000 $75.0000
OCTH -97166 OT EVAL MODERATE COMPLEXITY 3 3 2.082192 $106.3000 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 2 2 3.000000 $153.1500 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 1 1 1.000000 $51.0500 $51.0500
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 7 7 8.000000 $408.4000 $51.0500
SPCH -92521 EVAL OF SPEECH FLUENCY 3 3 5.000000 $255.2500 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 1 1 1.000000 $51.0500 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 11 12 12.038356 $614.5600 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 1 1 1.000000 $51.0500 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 2 2 2.000000 $89.1000 $44.5500
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Subtotal (Total Children Is Unduplicated) 537 905 1609.183333 $101435.7900 $63.0400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 13 14 15.666667 $78333.5000 $5000.0100
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 0.483333 $24.1700 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 3.714286 $265.9800 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 8 8 10.544444 $2425.2100 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 303 331 413.385892 $20669.3000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 36 37 43.269255 $1081.7300 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 101 114 211.534125 $10576.7000 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 0.400000 $10.0000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 30 32 46.972220 $2348.6000 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 60 65 91.588890 $4579.4500 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 2.566667 $64.1700 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 66 71 132.742858 $6637.1500 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 1.350000 $33.7500 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 664 703 4421.909533 $221095.4600 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 7 7 10.104761 $505.2400 $50.0000
INTR -T1013 INTERPRETER 136 163 516.434126 $25821.7200 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 855 1294 6234.067092 $62340.6700 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 37 39 268.076192 $19151.3800 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 1 1 1.266667 $72.4600 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 67 73 440.295238 $31454.7100 $71.4400
PHY -97110HM PT SESSION BY PT ASST 5 5 22.766667 $1301.3400 $57.1600
SENS -V5264 EARMOLD 3 3 0.969102 $17.4400 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 74 79 487.857139 $34852.5300 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 2 3 10.285714 $734.8100 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 10 10 55.152382 $765.5200 $13.8800
TRAV -TRAVS Travel by mile 882 1459 6463.324235 $2876.1800 $0.4500
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Subtotal (Total Children Is Unduplicated) 944 4517 19906.727485 $528039.1500 $26.5300
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Total 5531 23624.120338 $701597.4500 $29.7000
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Number of Children (Unduplicated) With at Least One Authorization 1009