Summary Report for FSPSAs Initiated During the Report Period Center: 02
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: 04-01-20 and 06-30-20 Date of Report: 07-20-20 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1593 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 3 3 13.030158 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 3 3 13.030158 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 25 26 18.291704 $887.1400 $48.5000
EVAL -96111 DEVELOPMENTAL EVALUATION 2 3 0.366666 $18.3300 $49.9900
EXIT -EXIT EXIT ASSESSMENT 38 38 39.975343 $1998.7700 $50.0000
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024GOTSGT F/U PHYC AND DEV EVAL BY OT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 2.000000 $111.0000 $55.5000
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 2 2 4.000000 $222.0000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 21 21 42.000000 $3150.0000 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 4 4 8.500000 $637.5000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 20 20 32.523286 $2439.2500 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 5 5 10.000000 $750.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 54 55 106.523286 $5912.0400 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 7 7 14.000000 $777.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 11 11 25.500000 $1912.5000 $75.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 2 2 0.491857 $25.1100 $51.0500
OCTF -97168GT OT RE-EVAL EST PLAN CARE 1 1 0.150685 $7.6900 $51.0500
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 5 5 8.445293 $431.1400 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 14 14 8.927777 $455.7600 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 4 4 1.175191 $60.0000 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 13 13 6.080518 $310.4100 $51.0500
SPCH -92521 EVAL OF SPEECH FLUENCY 4 4 4.000000 $204.2000 $51.0500
SPCH -92522TLGT EVAL OF SPCH SOUND PROD 1 1 1.000000 $51.0500 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 21 21 8.574050 $437.7100 $51.0500
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.112329 $5.7300 $51.0400
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 3 3 3.081801 $137.2900 $44.5500
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Subtotal (Total Children Is Unduplicated) 142 266 352.719786 $21442.6700 $60.7900
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 34 35 25.150532 $125752.5000 $4999.9900
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 49 56 68.292296 $3414.6200 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 5 5 3.849999 $192.5000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 15 15 12.020835 $300.5300 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 134 147 267.838095 $13391.9300 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 78 80 137.790479 $6889.5400 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 3 3 5.166667 $129.1700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 15 15 21.166667 $1058.3400 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 119 123 189.057145 $9452.8700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 5.999999 $150.0000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 141 145 879.628572 $43981.4200 $50.0000
INTR -T1013 INTERPRETER 13 16 35.773015 $1788.6500 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 150 275 1148.404766 $11484.0500 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 37 38 243.428571 $17390.5400 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 3 3 17.285714 $1234.8900 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 2 2 7.428571 $424.9200 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 30 31 207.174496 $14800.5400 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 4 4 27.714286 $1979.9000 $71.4400
PHY -97110HM PT SESSION BY PT ASST 1 1 3.357143 $191.8900 $57.1600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 33 33 173.435714 $12390.2300 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 1 1 9.428571 $673.5800 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 7 7 49.714285 $690.0400 $13.8800
TELEC -TELEC TELECONFERENCE,PROVIDER TO FAMILY,P 2 2 1.000000 $37.0000 $37.0000
TRAV -TRAVS Travel by mile 133 284 63927.809522 $28447.8800 $0.4500
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Subtotal (Total Children Is Unduplicated) 198 1324 67467.915940 $296247.4900 $4.3900
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Total 1593 67833.665884 $317690.1700 $4.6800
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Number of Children (Unduplicated) With at Least One Authorization 242