Summary Report for FSPSAs Ending During the Report Period Center: 05
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: 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 684 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 6 6 3.025397 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 6 6 3.025397 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
EXIT -EXIT EXIT ASSESSMENT 10 15 19.427398 $971.3700 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 3 4 4.010958 $300.8300 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 1 1 0.175342 $13.1500 $74.9800
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 3 4 2.268494 $170.1300 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 9 9 4.267124 $236.8200 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 3 3 0.012329 $0.9200 $74.8200
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 2 2 0.006850 $0.5100 $74.4500
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 8 8 0.042463 $2.3600 $55.6700
OCTH -97167 OT EVAL HIGH COMPLEXITY 2 2 1.197260 $61.1200 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 2 2 1.210959 $61.8200 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 0.378082 $19.3000 $51.0500
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Subtotal (Total Children Is Unduplicated) 38 53 34.997259 $1988.3300 $56.8100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.000000 $5000.0000 $5000.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 19 19 9.404046 $470.2100 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 207 221 232.803795 $11640.1900 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 2 2 0.300000 $7.5000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 81 84 77.486856 $3874.3500 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 2.800000 $70.0000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 87 89 98.467464 $4923.4000 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 156 170 168.823468 $8441.1800 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 0.233333 $5.8300 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 16 18 70.571428 $3528.5800 $50.0000
INTR -T1013 INTERPRETER 7 8 42.328572 $2116.4300 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 2 2 5.928572 $423.5300 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 2 2 5.142857 $367.4000 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 5 5 16.428572 $1173.6600 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 9.857143 $136.8200 $13.8800
TELEC -TELEC TELECONFERENCE,PROVIDER TO FAMILY,P 1 1 0.285714 $10.5700 $37.0000
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Subtotal (Total Children Is Unduplicated) 254 625 741.861820 $42189.6200 $56.8700
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Total 684 779.884476 $44177.9500 $56.6500
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Number of Children (Unduplicated) With at Least One Authorization 274