Summary Report for FSPSAs Initiated During the Report Period Center: 55
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 1317 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 15 15 17.214286 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 464.000000 $17168.0000 $37.0000
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Subtotal (Total Children Is Unduplicated) 16 16 481.214286 $17168.0000 $35.6800
Screening, Eval, and Assessment, Class # 02
EVAL -96111 DEVELOPMENTAL EVALUATION 20 22 21.804948 $1090.2600 $50.0000
EXIT -EXIT EXIT ASSESSMENT 42 42 70.155556 $3507.7800 $50.0000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 6 6 12.000000 $900.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 5 5 10.000000 $750.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 3 3 6.000000 $450.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 1 1 2.000000 $111.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 1 1 2.000000 $150.0000 $75.0000
OCTH -97167 OT EVAL HIGH COMPLEXITY 2 2 0.522222 $26.6600 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 5 5 1.855556 $94.7300 $51.0500
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Subtotal (Total Children Is Unduplicated) 74 88 127.338282 $7131.4700 $56.0000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 0.344444 $1722.0000 $4999.3600
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 1 1 0.455556 $22.7800 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 13 13 14.204365 $710.2200 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 2 2 0.716667 $17.9200 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 191 199 146.203172 $7310.1500 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 175 189 208.998420 $5224.9700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 104 189 109.788883 $5489.4200 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 66 116 118.788894 $2969.7400 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 26 47 26.055553 $1302.7700 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 15 29 22.288889 $557.2200 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 170 178 125.069838 $6253.4800 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 168 180 195.962705 $4899.0800 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 6.000000 $150.0000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 12 14 75.285714 $3764.2900 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 4 4 3.285714 $164.2900 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 2 2 8.571429 $612.3400 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 5 5 27.142857 $1552.5700 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 1 1 10.142857 $724.6100 $71.4400
PHY -97110HM PT SESSION BY PT ASST 2 2 25.571428 $1461.6700 $57.1600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 5 5 27.428572 $1959.4900 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 1 1 0.714286 $51.0300 $71.4400
TELEC -TELEC TELECONFERENCE,PROVIDER TO FAMILY,P 25 34 28.199999 $1043.4300 $37.0000
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Subtotal (Total Children Is Unduplicated) 310 1213 1181.220242 $47963.4200 $40.6000
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Total 1317 1789.772810 $72262.8900 $40.3800
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Number of Children (Unduplicated) With at Least One Authorization 357