Summary Report for FSPSAs Initiated During the Report Period Center: 01
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: 10-01-20 and 12-31-20 Date of Report: 01-23-21 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 4385 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 39 39 82.979362 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 7 7 205.095240 $7588.5300 $37.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 46 46 288.074602 $7588.5300 $26.3400
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 28 28 25.940183 $1258.0900 $48.5000
AUDE -92585 AUD EVOKED RESPONSE (COMP) 1 1 1.000000 $84.8400 $84.8400
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 1 1 3.142857 $160.5100 $51.0700
EXIT -EXIT EXIT ASSESSMENT 144 146 292.000000 $14600.0000 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 17 17 32.500000 $2437.5000 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 2 2 3.500000 $262.5000 $75.0000
IPDEF -T1024GOTSGT F/U PHYC AND DEV EVAL BY OT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 3 3 6.000000 $450.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 26 39 72.500000 $5437.5000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 13 14 27.500000 $1526.2500 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 151 151 290.000000 $21750.0000 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 10 10 20.000000 $1500.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 54 54 104.000000 $7800.0000 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 3 3 5.000000 $375.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 5 5 10.000000 $750.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 212 213 406.000000 $22533.0000 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 4 4 8.000000 $444.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 183 204 387.133334 $29035.0100 $75.0000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 7 7 13.000000 $975.0000 $75.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
OCTH -97166TLGT OT EVAL MODERATE COMPLEXITY 1 1 0.175342 $8.9500 $51.0400
PSTF -97164 PT RE-EVAL EST PLAN CARE 1 1 1.000000 $51.0500 $51.0500
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 2.000000 $102.1000 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 4 4 4.000000 $204.2000 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 5 5 9.714285 $495.9200 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 1 1 1.000000 $51.0500 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 9 9 6.509589 $332.3200 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 2 2 3.000000 $133.6500 $44.5500
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 538 928 1737.615590 $112959.4800 $65.0100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 20 20 25.756621 $128783.0000 $5000.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 2 2 2.000000 $100.0000 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 5 5 6.000000 $1380.0000 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 225 267 320.060426 $16003.0100 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 5 6 1.526026 $76.3100 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 48 52 47.076713 $1176.9200 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 99 109 252.917459 $12645.8700 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 8 8 12.750001 $637.5100 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 7 7 7.566666 $189.1700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 37 40 98.700001 $4935.0100 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 3 3 7.200000 $360.0000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 3 3 16.538096 $413.4500 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 51 53 106.477778 $5323.8900 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 3 3 3.466666 $173.3300 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 78 79 183.615876 $9180.8100 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 3 3 6.800000 $340.0000 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 6 6 7.066667 $176.6700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 501 524 3723.422183 $186171.2100 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 11 11 59.533332 $2976.6800 $50.0000
INTR -T1013 INTERPRETER 129 154 427.107957 $21355.4100 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 661 942 5312.699958 $53127.0300 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 31 35 278.571429 $19901.1500 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 1 1 11.428571 $653.7200 $57.2000
OCCT -97530TL OT SESSION BY LICENSED OT 2 2 17.600000 $1257.3400 $71.4400
OCCT -97530TLGT OT SESSION BY LICENSED OT 1 1 9.142857 $653.1700 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 53 54 338.342855 $24171.2300 $71.4400
PHY -97110TLGT PT SESSION BY LICENSED PT 3 3 9.999999 $714.4000 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 57 62 431.071427 $30795.7600 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 2 2 15.714286 $1122.6300 $71.4400
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 1 1 6.285714 $449.0500 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 4 4 35.571429 $2541.2200 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 4 4 17.142856 $237.9500 $13.8800
TRAV -TRAVS Travel by mile 661 945 5298.152338 $2357.6800 $0.4400
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 730 3411 17097.306187 $530380.5300 $31.0200
-------------------------------------------------------------------------------------------------------------------------------------
Total 4385 19122.996379 $650928.5400 $34.0400
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 823