Summary Report for FSPSAs Initiated During the Report Period Center: 05
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 1614 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 6.199999 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 2 2 1.044445 $38.6500 $37.0000
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Subtotal (Total Children Is Unduplicated) 8 8 7.244444 $38.6500 $5.3300
Screening, Eval, and Assessment, Class # 02
EXIT -EXIT EXIT ASSESSMENT 14 14 21.000000 $1050.0000 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 11 12 10.021918 $751.6400 $75.0000
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 1 1 1.000000 $75.0000 $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 6 6 10.175342 $763.1500 $75.0000
IPDEF -T1024GPTSGT F/U PHYC AND DEV EVAL BY PT 1 1 1.000000 $75.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 11 12 4.035619 $302.6500 $74.9900
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 36 37 26.888458 $1492.2700 $55.5000
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 4 4 2.008220 $111.4500 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 52 54 0.179467 $13.3500 $74.3900
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 32 32 0.121922 $9.1100 $74.6800
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 69 69 0.223300 $12.2800 $55.0200
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 11 11 0.326030 $24.4200 $74.9000
OCTF -97168 OT RE-EVAL EST PLAN CARE 1 1 1.000000 $51.0500 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 5 5 2.361111 $120.5300 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 29 29 13.663623 $697.5300 $51.0500
OCTH -97167TLGT OT EVAL HIGH COMPLEXITY 1 1 0.116667 $5.9600 $51.0600
PSTH -97162 PT EVAL MODERATE COMPLEXITY 2 2 0.738889 $37.7200 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 23 23 12.852665 $656.1400 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 2 2 2.000000 $102.1000 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 65 65 64.113633 $3273.0000 $51.0500
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.183333 $9.3600 $51.0400
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 1 1 0.208219 $10.6300 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 6 6 5.766667 $256.9100 $44.5500
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Subtotal (Total Children Is Unduplicated) 233 391 183.985083 $10201.2300 $55.4500
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 5 5 4.500000 $22500.0000 $5000.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 16 16 9.371855 $468.6000 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 204 217 240.525790 $12026.2600 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 11 11 3.923809 $196.1900 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 2.766667 $69.1700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 64 65 65.051982 $3252.6000 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 2 2 0.919047 $45.9500 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 2.966667 $74.1700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 79 82 88.051186 $4402.5400 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 4 4 1.622222 $81.1100 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 150 162 161.210315 $8060.5000 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 5 5 0.816666 $40.8300 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 4 4 4.705555 $117.6400 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 8 8 58.571429 $1464.2900 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 216 235 1435.409526 $71770.4500 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 72 74 174.228571 $8711.4600 $50.0000
INTR -T1013 INTERPRETER 3 3 11.185715 $559.2900 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 38 41 207.571431 $14828.9100 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 23 23 39.561905 $2826.3000 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 5 5 27.392857 $1566.8700 $57.2000
OCCT -97530TL OT SESSION BY LICENSED OT 1 1 0.571429 $40.8200 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 44 47 305.204763 $21803.8300 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 13 13 24.138096 $1724.4300 $71.4400
PHY -97110HM PT SESSION BY PT ASST 4 4 23.142857 $1322.8500 $57.1600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 103 106 587.785713 $41991.4300 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 34 34 64.857142 $4633.4100 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 3 3 2.142857 $153.0900 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 8 8 55.000000 $763.4000 $13.8800
TELEC -TELEC TELECONFERENCE,PROVIDER TO FAMILY,P 31 35 27.390477 $1013.4500 $37.0000
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Subtotal (Total Children Is Unduplicated) 350 1215 3630.586529 $226509.8100 $62.3900
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Total 1614 3821.816056 $236749.6900 $61.9500
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Number of Children (Unduplicated) With at Least One Authorization 405