Summary Report for FSPSAs Ending During the Report Period Center: 57
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: 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 1360 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 41 42 17.231748 $637.5800 $37.0000
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Subtotal (Total Children Is Unduplicated) 41 42 17.231748 $637.5800 $37.0000
Screening, Eval, and Assessment, Class # 02
OCTF -97168 OT RE-EVAL EST PLAN CARE 1 1 0.338889 $17.3000 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 25 26 13.237302 $675.7700 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 1 1 0.338889 $17.3000 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 9 9 3.988889 $203.6300 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 20 20 9.631747 $491.7100 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 3 3 0.677778 $30.2000 $44.5500
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Subtotal (Total Children Is Unduplicated) 38 60 28.213494 $1435.9100 $50.8900
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 2 3 0.077778 $3.8900 $50.0100
CONOF -CONOF CONSULT, OT, FACE TO FACE 142 145 86.309526 $4315.5000 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 30 30 20.660318 $1033.0200 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 215 219 110.932537 $5546.6300 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 30 30 146.571428 $3664.2900 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 368 377 2311.384149 $115569.2000 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 366 376 2305.001610 $23050.0100 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 29 29 94.642860 $6761.2800 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 2 3 18.428572 $1054.1200 $57.2000
OCCT -97530TL OT SESSION BY LICENSED OT 1 1 8.571429 $612.3400 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 10 10 40.142856 $2867.8200 $71.4400
PHY -97110TL PT SESSION BY LICENSED PT 1 1 8.714286 $622.5500 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 33 33 94.428574 $6745.9800 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 8.714286 $120.9500 $13.8800
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Subtotal (Total Children Is Unduplicated) 400 1258 5254.580209 $171967.5700 $32.7300
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Total 1360 5300.025451 $174041.0600 $32.8400
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Number of Children (Unduplicated) With at Least One Authorization 443