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: 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 732 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 14 14 29.104764 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 14 14 29.104764 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
EXIT -EXIT EXIT ASSESSMENT 6 7 10.200000 $510.0000 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 4 4 8.000000 $444.0000 $55.5000
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 3 3 0.013698 $0.7600 $55.5000
OCTH -97166 OT EVAL MODERATE COMPLEXITY 1 1 0.388889 $19.8500 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 2 2 0.147946 $7.5600 $51.0700
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 4 4 0.087672 $4.4700 $51.0100
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Subtotal (Total Children Is Unduplicated) 19 23 22.838205 $1286.6400 $56.3400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 1.283333 $6416.5000 $4999.8700
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 15 15 78.691194 $3934.5600 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 12 13 9.287769 $464.3900 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 201 218 208.078567 $10403.9100 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 15 17 19.538888 $976.9400 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 1.466667 $36.6700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 68 70 62.546429 $3127.3200 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 4 4 4.661111 $233.0600 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 2.100000 $52.5000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 85 90 136.794838 $6839.7200 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 5 5 5.716666 $285.8300 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.016667 $0.4200 $25.0500
CONSF -CONSF CONSULT, SLP, FACE TO FACE 165 179 166.045241 $8302.2800 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 7 7 6.727777 $336.3900 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 0.533333 $13.3300 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 21 22 77.428571 $3871.4300 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 12 13 85.857141 $4292.8700 $50.0000
INTR -T1013 INTERPRETER 5 5 29.285714 $1464.2900 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 1 1 1.466667 $14.6700 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 3 3 9.000000 $642.9500 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 2.857143 $204.1100 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 2 2 10.219047 $730.0500 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1 1 4.714286 $336.7900 $71.4400
TELEC -TELEC TELECONFERENCE,PROVIDER TO FAMILY,P 23 23 57.508333 $2127.8000 $37.0000
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Subtotal (Total Children Is Unduplicated) 267 695 981.825382 $55108.7400 $56.1300
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Total 732 1033.768351 $56395.3800 $54.5500
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Number of Children (Unduplicated) With at Least One Authorization 282