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 3872 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 41 41 111.595236 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 0.066667 $2.4700 $37.0200
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Subtotal (Total Children Is Unduplicated) 43 43 112.495236 $33.3000 $0.3000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 18 20 18.240563 $884.6600 $48.5000
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 1 1 2.000000 $76.9400 $38.4700
AUDE -92585 AUD EVOKED RESPONSE (COMP) 1 1 1.000000 $84.8400 $84.8400
EXIT -EXIT EXIT ASSESSMENT 164 166 331.000000 $16550.0000 $50.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 1 2 3.000000 $225.0000 $75.0000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 3 3 5.000000 $375.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 13 13 24.000000 $1332.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 12 13 25.000000 $1875.0000 $75.0000
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 2 3 4.000000 $204.2000 $51.0500
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Subtotal (Total Children Is Unduplicated) 198 222 413.240563 $21607.6400 $52.2900
EI Services, Class # 03
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 1.000000 $230.0000 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 301 329 410.385892 $20519.3000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 36 37 43.269255 $1081.7300 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 100 113 210.850792 $10542.5400 $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 59 64 90.905557 $4545.2900 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 2.566667 $64.1700 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 65 70 131.076191 $6553.8200 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 1.350000 $33.7500 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 38 40 314.033334 $15701.6800 $50.0000
INTR -T1013 INTERPRETER 134 161 513.434126 $25671.7200 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 855 1293 6221.352806 $62213.5200 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 1 1 9.285714 $663.3700 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 2 2 8.142857 $581.7300 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1 1 3.285714 $234.7300 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 7.571429 $105.0900 $13.8800
TRAV -TRAVS Travel by mile 882 1458 6450.609949 $2870.5200 $0.4500
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Subtotal (Total Children Is Unduplicated) 937 3607 14466.492503 $153971.5400 $10.6400
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Total 3872 14992.228302 $175612.4800 $11.7100
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Number of Children (Unduplicated) With at Least One Authorization 955