Summary Report for FSPSAs Initiated During the Report Period Center: 04
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 1397 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 19 19 12.177776 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 19 19 12.177776 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
NURS -T1001 NURSING ASSESSMENT 1 1 1.571429 $78.5700 $50.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 4 4 0.716667 $36.5900 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 2 2 0.372222 $19.0000 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 49 51 11.561113 $590.2000 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 1 1 0.288889 $14.7500 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 25 26 6.083335 $310.5600 $51.0500
SPCH -92521 EVAL OF SPEECH FLUENCY 1 1 0.316667 $16.1700 $51.0600
SPCH -92522 EVAL OF SPCH SOUND PROD 1 1 0.216667 $11.0600 $51.0600
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 21 21 4.222220 $215.5300 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 1 1 0.288889 $14.7500 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 4 4 1.155556 $51.4800 $44.5500
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Subtotal (Total Children Is Unduplicated) 87 113 26.793654 $1358.6700 $50.7100
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 8 20 2.477775 $123.8800 $49.9900
CONIP -CONIP CONSULT, ITDS PHONE 3 3 1.355556 $33.8900 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 11 11 2.605556 $130.2800 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 1 1 6.285714 $314.2900 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 6 6 2.966667 $74.1700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 9 9 8.002380 $400.1200 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 1 1 0.088889 $4.4500 $50.0100
CONPP -CONPP CONSULT, PT, PHONE 3 3 1.716667 $42.9200 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 10 10 5.470635 $273.5400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 5 5 2.438889 $60.9700 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 55 68 419.999995 $10500.0100 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 452 484 3461.928544 $173096.5100 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 1 1 8.714286 $435.7200 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 443 470 3370.620608 $33706.2200 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 56 57 326.142854 $23299.6600 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 5.285714 $377.6100 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 20 21 117.642855 $6729.1800 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 36 37 196.714286 $14053.2600 $71.4400
PHY -97110HM PT SESSION BY PT ASST 7 7 48.000000 $2743.6800 $57.1600
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 1 1 12.142857 $694.0900 $57.1600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 40 41 189.857143 $13563.4100 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 2 12.857143 $735.4300 $57.2000
SPL -92508 GROUP SPL SESSION PER CHILD 6 6 42.571430 $590.8900 $13.8800
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Subtotal (Total Children Is Unduplicated) 530 1265 8245.886443 $281984.1300 $34.2000
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Total 1397 8284.857873 $283342.8000 $34.2000
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Number of Children (Unduplicated) With at Least One Authorization 546