Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 55
This report estimates subtotals of units and fees for the number of days of overlap between each included
FSPSA record and the user-selected report period. For example, if the FSPSA record authorizes services from
01/01/01 to 08/01/01, and the Report Period is selected as 01/01/01 to 03/01/01, this summary calculates
authorized units/fees for the 28 days of overlap (02/01/01 to 03/01/01). Note that service authorization periods
may range from 1 to 12 months and may vary in intensity from child to child.
FSPSAs overlapping: 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 1772 FSPSA's found
Services Cpt Code Number of Number of Total Units Total Fees Avg Fee
Children Records Overlapping Overlapping Per Unit Auth
Report Period Report Period
Service Coordination, Class # 01
SCONLY-SCONLY *SERVICE COORDINATION ONLY 91 93 5112.822220 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 9 9 1330.800000 $49505.7600 $37.2000
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Subtotal (Total Children Is Unduplicated) 100 102 6443.622220 $49505.7600 $7.6800
Screening, Eval, and Assessment, Class # 02
EVAL -96111 DEVELOPMENTAL EVALUATION 2 2 0.622223 $31.1200 $50.0100
EVAL -96111GT DEVELOPMENTAL EVALUATION 4 4 7.000000 $350.0000 $50.0000
IPDEF -T1024GPTSGT F/U PHYC AND DEV EVAL BY PT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 2 2 0.109590 $8.2200 $75.0100
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 2.000000 $111.0000 $55.5000
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 1 1 2.000000 $111.0000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 12 12 24.000000 $1800.0000 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 2 2 4.000000 $300.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 1 1 2.000000 $150.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 9 9 18.000000 $1350.0000 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 1 1 2.000000 $150.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 3 3 6.000000 $333.0000 $55.5000
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 9 11 3.761113 $193.3700 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 9 9 8.100000 $416.4200 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 5 6 1.616666 $83.1100 $51.4100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 1 1 0.133333 $6.8500 $51.4000
PSTH -97163 PT EVAL HIGH COMPLEXITY 1 1 0.033333 $1.7100 $51.3600
SPCH -92521 EVAL OF SPEECH FLUENCY 4 4 2.405556 $123.6700 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 17 21 9.827776 $505.2400 $51.4100
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Subtotal (Total Children Is Unduplicated) 57 93 97.609590 $6285.7100 $64.4000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 4 5 5.238889 $26194.5000 $5000.0100
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 23 23 18.244444 $912.2200 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 1 2 2.000000 $100.0000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 6 6 9.227778 $230.7000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 251 305 219.288080 $10964.3300 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 3 3 2.077777 $103.8900 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 116 137 188.522227 $4713.0700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 173 324 216.788880 $10839.4000 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 2 4 4.022222 $201.1100 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 58 133 179.422214 $4485.5400 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 47 106 64.955552 $3247.7600 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 21 44 61.277781 $1531.9500 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 182 208 142.195224 $7109.7000 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 5 5 4.233332 $211.6600 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 122 144 182.833336 $4570.8400 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 24 29 224.428572 $11221.4500 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 14 16 118.080159 $8497.0400 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 13.142857 $945.7600 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 15 19 148.428571 $8549.4800 $57.6000
OCCT -97530HMGT OT SESSION BY OT ASST 2 2 10.000000 $576.0000 $57.6000
PHY -97110 PT SESSION BY LICENSED PT 8 8 62.714286 $4512.9200 $71.9600
PHY -97110HM PT SESSION BY PT ASST 8 10 55.780953 $3210.7400 $57.5600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 35 42 352.357145 $25355.6200 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 1 1 10.428571 $750.4400 $71.9600
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Subtotal (Total Children Is Unduplicated) 415 1577 2295.688850 $139036.1100 $60.5600
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Total 1772 8836.920660 $194827.5800 $22.0500
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Number of Children (Unduplicated) With at Least One Authorization 494