Summary Report for FSPSAs Initiated During the Report Period Center: 05
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 1097 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 12 12 12.622223 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 0.011111 $0.4100 $37.1600
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Subtotal (Total Children Is Unduplicated) 13 13 12.633334 $0.4100 $0.0300
Screening, Eval, and Assessment, Class # 02
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 4 4 6.500000 $487.5000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 3 3 6.000000 $450.0000 $75.0000
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 2 2 2.022222 $151.6700 $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 4 4 6.000000 $450.0000 $75.0000
IPDEF -T1024GPTSGT F/U PHYC AND DEV EVAL BY PT 2 2 4.000000 $300.0000 $75.0000
IPDEF -T1024TLTSGT F/U PHYC AND DEV EVAL BY EI PROF 1 1 0.005556 $0.4200 $75.5900
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 13 14 21.522222 $1194.4800 $55.5000
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 5 5 10.000000 $555.0000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 42 42 80.505479 $6037.9100 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 34 34 67.000000 $5025.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 3 3 6.000000 $450.0000 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 31 31 62.000000 $4650.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 39 39 78.000000 $5850.0000 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 16 16 31.500000 $2362.5000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 47 47 91.505479 $5078.5600 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 55 56 109.500000 $6077.2500 $55.5000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 1 1 2.000000 $150.0000 $75.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 9 9 3.743151 $192.4400 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 3 3 0.677549 $34.8300 $51.4100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 1 1 0.077778 $4.0000 $51.4200
PSTF -97164 PT RE-EVAL EST PLAN CARE 1 1 1.000000 $51.4100 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 4 4 3.150000 $161.9400 $51.4100
PSTH -97161TL PT EVAL LOW COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 2 2 2.000000 $102.8200 $51.4100
PSTH -97163TL PT EVAL HIGH COMPLEXITY 3 3 1.561111 $80.2600 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 13 13 13.172222 $677.1800 $51.4100
SPCH -92521GT EVAL OF SPEECH FLUENCY 1 1 1.000000 $51.4100 $51.4100
SPCH -92521TL EVAL OF SPEECH FLUENCY 1 1 1.000000 $51.4100 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 5 5 0.566667 $29.1300 $51.4100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 1 2 13.000000 $668.3300 $51.4100
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Subtotal (Total Children Is Unduplicated) 170 352 630.009436 $41726.8600 $66.2300
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 2.000000 $10000.0000 $5000.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 23 27 24.561111 $1228.0600 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 7 8 9.500000 $475.0000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 1.000000 $25.0000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 131 137 201.761795 $10088.0900 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 38 38 58.962699 $2948.1400 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 52 56 53.802379 $2690.1100 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 33 35 42.658730 $2132.9400 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 2.142857 $53.5700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 47 49 77.057940 $3852.9100 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 18 18 18.895240 $944.7700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 75 80 103.658729 $5182.9200 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 34 35 43.259525 $2162.9800 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 5.011110 $125.2800 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 2 2 1.200000 $30.0000 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 6.500000 $325.0000 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 146 156 966.339694 $48316.9600 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 23 23 107.000002 $5349.9900 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 14 16 71.857143 $5170.8400 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 2 2 8.255556 $594.0700 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 21 23 135.857144 $9776.2800 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 1 1 4.714286 $339.2400 $71.9600
PHY -97110TL PT SESSION BY LICENSED PT 1 1 8.714286 $627.0800 $71.9600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 13 14 78.295241 $5634.1200 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 3 3 12.000001 $863.5100 $71.9600
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Subtotal (Total Children Is Unduplicated) 190 732 2045.005468 $118936.8200 $58.1600
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Total 1097 2687.648238 $160664.0900 $59.7800
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Number of Children (Unduplicated) With at Least One Authorization 278