Summary Report for FSPSAs Initiated During the Report Period Center: 57
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 1473 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
TCM -T1017TL TARGETED CASE MANAGEMENT 149 150 100.550791 $3720.3700 $37.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 149 150 100.550791 $3720.3700 $37.0000
Screening, Eval, and Assessment, Class # 02
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 1 1 0.428571 $32.1500 $75.0100
OCTH -97167 OT EVAL HIGH COMPLEXITY 18 20 7.716665 $393.9300 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 1 1 0.272222 $13.9000 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 7 7 2.788888 $142.3700 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 14 14 3.416665 $174.4100 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 3 3 1.561111 $69.5500 $44.5500
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 26 46 16.184122 $826.3000 $51.0600
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1 2 0.300000 $15.0000 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 133 136 64.049215 $3202.5000 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 27 27 17.849208 $892.4700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 198 201 109.000799 $5450.0600 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 41 52 189.857144 $4746.4100 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 350 361 2293.980947 $114699.0400 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 348 361 2274.315866 $22743.1600 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 44 54 117.499990 $8394.2700 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 1 1 1.928571 $110.3200 $57.2000
OCCT -97530TL OT SESSION BY LICENSED OT 1 1 4.714286 $336.7900 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 16 20 48.428567 $3459.7600 $71.4400
PHY -97110HM PT SESSION BY PT ASST 1 1 1.928571 $110.2400 $57.1600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 44 55 133.499991 $9537.3100 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 5 5 7.928571 $110.0500 $13.8800
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 398 1277 5265.281726 $173807.3600 $33.0100
-------------------------------------------------------------------------------------------------------------------------------------
Total 1473 5382.016639 $178354.0300 $33.1400
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 483