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Documenting Music Therapy on the MDS 3.0

Here’s some important news for long-term care facilities and music therapists working in them: Music therapy can now be documented as a skilled service on the MDS. The Long-Term Care Minimum Data Set, version 3.0 (MDS 3.0) is the primary screening and assessment tool for long-term care facilities. It is required for all residents of facilities certified to participate in Medicare and Medicaid, regardless of who is paying the bill for an individual resident. The data collected on the MDS are used as the basis for care-planning for individual residents, and in aggregate, the data collected on the MDS form an important source of information for researchers and policymakers.

Why should I document music therapy on the MDS?

It might seem like so much unnecessary paperwork to document music therapy on the MDS, but while it will not directly affect reimbursement now, it does provide official, standardized documentation of the music therapy services your facility provides. First of all, this documentation is simply good professional practice (after all, if it’s not documented, it didn’t happen, right?). Secondly, it helps to distinguish the skilled services provided by a board-certified music therapist from the recreational or entertainment services provided by other musicians or volunteers. If your facility is providing this extra, skilled service, you want that to be known to residents, families, staff members, and regulators. Finally, as data are collected showing that music therapy (and recreation therapy) services are being provided, researchers and policymakers will start taking notice, and this may lead to improved reimbursement and access to services in the future.

How do I document music therapy on the MDS?

Music therapy is listed in Section O (0400) – Therapies, together with Recreation Therapy. For the seven-day look-back period, you should document the number of minutes your resident has spent in music therapy as well as the number of days spending at least 15 minutes in music therapy. Residents may be in group or individual music therapy. To document music therapy on the MDS, the following requirements must be met:

1. The physician orders the music therapy, including the frequency, duration, and scope of music therapy.

2. The therapy must be based on an active, written treatment plan based on an assessment by the music therapist.

3. The services are provided by qualified personnel (such as an MT-BC).

4. The services must be reasonable and necessary for treatment of the resident’s condition.

The MDS coordinator for a facility should review the clinical documentation maintained by the music therapist as well as consulting that professional in person to ensure complete and appropriate documentation of music therapy services.

Where can I get more information?

More information on documenting music therapy appropriately may be found on the website for the Centers for Medicare and Medicaid Services (CMS). The RAI manual provides detailed information on how to document therapies appropriately, and this video from CMS features a lecture on documenting on the MDS 3.0. (Start at 48:00 for information specific to Section 0 – 0400).

This is an exciting development for the practice of music therapy in long-term care. Big thanks to Judy Simpson, the government relations director for the American Music Therapy Association, for explaining to me how this has developed! Since I just learned these details recently, I haven’t pursued this yet with my own clients, but I will soon be speaking with the MDS coordinators at the facilities I serve about this very topic.

Have you already started documenting music therapy on the MDS 3.0? Tell us about your successes or any snags you have encountered.

10 comments… add one
  • Erin

    Hi Rachelle,
    I really enjoyed this post and think it is great that music therapy is FINALLY included as an intervention. I used to document on the MDS when I was employed full-time in a SNF/Ortho Rehab center. This was pre-MDS 3.0 (and nearly 5 years ago), so I can’t exactly remember the sections I documented under. I do know that even when I was referred to do co-treatment with PT, OT or restorative nursing, I could not document it as such (not as recreation) because services could not be billed, or entered twice. This is also true when billing with CPT codes.

    My work with nursing homes as a contractor has not required that I document. I have only done rather large groups (16-20), though and it probably got bunched in with entertainment.

    It seems strange that even with a physician referral, the service is not reimbursable. However, I think that the more services are used over-all influences reimbursement somehow.

    Do you document in this way? This system is much less onerous that other documentation systems I have used and if I were to document as a contractor, it would be a pretty quick and easy thing to do. Do you think having music therapy listed in the documentation system encourages facilities to contract for that service?

    Sorry if it’s a bit jumbly, my brain still on infant-care-taking mode :/

    • soundscapemusictherapy

      Hi Erin! Thanks for your comment. I agree that it is exciting that we can document music therapy specifically on the MDS now. I think before some folks were able to chart under the restorative care section – maybe that’s how it worked at your previous facility?

      From what I understand, I believe that documentation on the MDS has to be based on information already in the resident’s record. That means there should already be an assessment and sessions notes/progress reports in place, as well as the doctor’s order. I do have assessments and sessions notes that I use for all of the facilities I contract with, including the larger groups, but I might have to adapt them somewhat to meet requirements for each facility’s medical record. (In some facilities, for example, I use a group log with one line per each attendee, and these logs are maintained in a music therapy notebook by the activity director. I might have to switch to having notes in each resident’s chart – I’ll have to figure out how to do that most efficiently.) I haven’t started documenting on the MDS yet, but I hope we will figure out how to make that work at each facility I serve in the near future!

      I also agree that it’s odd that this service is not directly reimbursable, but I do think it will help to have standardized documentation in place, especially to differentiate MT from other musical activities. I’ve had one activity director tell me her facility is documenting MT on the MDS and that it can increase their RUG score, which would increase reimbursement levels, but I’m not the MT at that facility, so I don’t know the details of how they’re making that work.

      I don’t know yet whether documenting on the MDS will encourage facilities to hire MTs, but I don’t see how it could hurt. Again, I think it’s one more way to show that the services provided by an MT-BC are different from other activity offerings in that they are skilled services to address therapeutic needs.

      Thanks for writing in! And by the way, I definitely understand infant-care-taking mode, too. No worries! 🙂

      • Carolyn

        I’m so glad you posted this. I have been researching this topic for months now and it seems that there are very few people who know very little! HA! I’m referring to the SNF MDS Coordinators, ADs and other therapists.
        I was trying to figure out exactly what was the reimbursement benefit for the facility and what I’m understanding from your posts is that there really is no direct $$ benefit for suddenly hiring a MT to fill Dr.s orders for services on Section O-0400. But that it MAY increase overall RUG-IV levels for the facility.
        This is important information since the bottom line is really, How can the SNF increase its revenue by hiring an MT for this section of the MDS.

        • soundscapemusictherapy

          Hi, Carolyn! You’re right – the bottom line is always how the SNF will increase revenue. It’s frustrating to give answers of “maybe” and “we don’t know yet,” but it does seem that this can only help nursing homes who want to provide the best care. Hopefully the reimbursement will follow sooner rather than later!

  • Emily MacPherson

    I was hoping you’d be able to clear something up for me… in Belgrave, Darrow, Walworth and Wlodarczyk’s “Music Therapy and Geriatric Populations: A Handbook for Practicing Music Therapist and Healthcare Professionals” it says that you can access additional funding for facilities by documenting under Restorative Care. It goes on to address documenting under Section O, but says there is no additional reimbursement for the facility through this documentation.

    So my question is has something maybe changed that would make documenting in Section O better, or should I document under Restorative Care for the bonus of additional funding? I’m trying to get a better documentation system for MT at my facility but I want to make sure I know what’s going on first!! 🙂

    • soundscapemusictherapy

      Hi, Emily,
      Props to you for working to figure this one out! Unfortunately, I don’t have a good answer on how to choose between documenting in Section O or under restorative care. There are clear distinctions in the RAI manual (p. O-19) between skilled therapies and restorative care when it comes to PT, OT and speech therapy, but apparently respiratory, psychological, and recreational (music) therapies don’t have to meet the skilled therapy requirements. Restorative care is a nursing program, supervised by nursing staff, but the RAI manual (p. O-29) specifies that non-nursing staff can provide restorative care under the supervision of a nurse. For example, if a PT did a maintenance program with a resident (not a skilled service), the minutes would count under restorative care. This is how music therapy has been documented before, and, yes, the more extensive the restorative care program, the better the RUG level, and thus the better the reimbursement rate for the nursing home. My understanding is that documenting music therapy in Section O still does not affect reimbursement. That really complicates the documentation issue for music therapy, doesn’t it? It seems like it would be a clearer documentation of music therapy to put it in Section O, but the reimbursement might be better with it under restorative care. I haven’t been able to get a better answer from anyone else either, so maybe it will take music therapists trying both and seeing what happens. I’d love to know what you end up doing in your facility!

  • Ok, let me make sure I’ve got this correct…. If I contract with a SNF to provide MT services for a group of their residents, I need a physicians orders before I could document in the MDS for my group. Additionally, I’d only document in the MDS *for those participants* who had physician’s orders, plus I’d need to complete assessments and ongoing progress notes for those participants.

    Rachelle, since it sounds like you’re already doing these things for your contract groups– how does it work? If I can ask, what sort of paperwork system do you have in place? In the past, I’ve worked full-time as an MT for a SNF but have just recently begun trying to get contracts with them. And full-time work is much different than contract as far as time management and paperwork goes! I’m also assuming you’ve built your paperwork time into your fee for the facility. Do you ever attend care plan meetings, or just leave reports?

    Thanks for the great post! Sorry I’m a few months behind in finding it. 🙂

    • soundscapemusictherapy

      Hi Stephanie,

      You’ve got it right as far as I understand it. The one hitch with documenting music therapy groups is that there may be a requirement for a 4:1 resident to staff ratio, as is required with restorative care groups. To be honest, I haven’t perfected the documentation system yet with any of my contracted nursing homes. For some of them, the groups are clearly too large to document as music therapy (10+), and I’ve made sure my contacts there understand that. I’ve been working first with the two places I do 1:1 sessions for documenting on the MDS, and we haven’t *quite* gotten the documentation down. They need to make a place for MT documentation in the residents’ charts, and we need to figure out exactly how to write the physicians’ orders. I already have assessments and individual notes in place, although I’ve been doing all of the individual notes on one piece of paper for simplicity’s sake since they didn’t want them in the residents’ charts before. I’ll have to start writing individual progress notes to place in the charts. One facility I think will also have me fill out time logs the same way their PTs and OTs do, to make it easier for the MDS coordinators to keep track of which residents receive MT and when. Eventually, we’ll work on getting the staffing ratios right to be able to document group music therapy as well.

      I always include documentation time as part of my contracts. I leave about 10 minutes of each hour to complete paperwork. (Setting up a new system is taking extra time beyond that right now, but for a very good reason.) I have not attended care plan meetings in SNFs in the past, although I always offer to do so. I do keep in close contact with (usually) the activity director, so they can pass on my reports to the care plan team.

      Let me know if you have any other questions for me, and good luck getting everything in place!

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