Summary Report for FSPSAs Initiated During the Report Period Center: 02
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: 10-01-23 and 12-31-23 Date of Report: 01-14-24 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1037 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 2 2 3.077778 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 2 2 3.077778 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 16 16 10.415829 $505.1700 $48.5000
EXIT -EXIT COS Exit 4 4 2.750000 $137.5000 $50.0000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 1 1 0.005479 $0.4100 $75.2900
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 1 1 2.000000 $150.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 1 1 0.005479 $0.3100 $55.7000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 1 1 2.000000 $111.0000 $55.5000
OCTF -97168 OT RE-EVAL EST PLAN CARE 1 1 0.052055 $2.6800 $51.4600
OCTH -97166 OT EVAL MODERATE COMPLEXITY 1 1 0.338889 $17.4200 $51.4100
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 1 1 0.038356 $1.9700 $51.4700
PSTH -97162 PT EVAL MODERATE COMPLEXITY 1 1 0.038356 $1.9700 $51.4700
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 0.038356 $1.9700 $51.4700
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 1 1 2.000000 $102.8200 $51.4100
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Subtotal (Total Children Is Unduplicated) 24 30 19.682799 $1033.2300 $52.4900
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 39 40 36.707994 $1835.4100 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 3 3 3.250000 $162.5000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 3 3 4.066666 $101.6700 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 131 146 273.719040 $13685.9100 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 2.000000 $50.0000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 89 89 158.428564 $7921.4000 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 2 2 2.366666 $118.3300 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 2 2 3.400000 $85.0000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 4 4 11.676516 $583.8300 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.466667 $11.6700 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 123 124 238.560309 $11927.9700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 3.100000 $77.5000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 3 3 11.857142 $592.8600 $50.0000
INTR -T1013 INTERPRETER 18 27 60.906913 $3045.3500 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 115 228 1063.648343 $12763.7600 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 4 4 18.000001 $1295.2800 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 2 2 11.142857 $801.8400 $71.9600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1 1 4.571429 $328.9600 $71.9600
TRAV -TRAVS Travel by mile 138 322 63492.120417 $28253.9900 $0.4500
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Subtotal (Total Children Is Unduplicated) 200 1005 65399.989524 $83643.2200 $1.2800
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Total 1037 65422.750101 $84676.4500 $1.2900
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Number of Children (Unduplicated) With at Least One Authorization 203