Summary Report for FSPSAs Ending During the Report Period Center: 51
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 367 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 8 8 11.909523 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 2.600000 $96.2000 $37.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 9 9 14.509523 $96.2000 $6.6300
Screening, Eval, and Assessment, Class # 02
EXIT -EXIT EXIT ASSESSMENT 5 5 6.714286 $335.7200 $50.0000
OCTH -97166 OT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 18 18 16.606349 $847.7600 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 5 5 5.000000 $255.2500 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 9 9 9.000000 $459.4500 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 5 5 5.285714 $235.4800 $44.5500
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 40 43 43.606349 $2184.7000 $50.1000
EI Services, Class # 03
CONIF -CONIF CONSULT, ITDS FACE TO FACE 4 4 5.100000 $255.0000 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 0.022222 $0.5600 $24.9800
CONOF -CONOF CONSULT, OT, FACE TO FACE 1 1 0.266667 $13.3400 $50.0100
CONSP -CONSP CONSULT, SLP, PHONE 1 1 0.022222 $0.5600 $24.9800
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 80 83 699.128567 $34956.4300 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 81 84 671.857140 $47997.5100 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 3.857143 $275.5500 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 21 22 152.659523 $10905.9800 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 110 112 860.604758 $61481.6600 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 1 1 12.285714 $877.6900 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 7.142857 $408.5700 $57.2000
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 11.285714 $156.6500 $13.8800
TELEC -TELEC TELECONFERENCE,PROVIDER TO FAMILY,P 2 2 7.690476 $284.5400 $37.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 218 315 2431.923003 $157614.0300 $64.8100
-------------------------------------------------------------------------------------------------------------------------------------
Total 367 2490.038875 $159894.9300 $64.2100
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 246