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.