In this AMTA.Pro on-line symposium, Music Therapy Reimbursement, Judy Simpson, AMTA’s Director of Government Relations, provides helpful information about the primary sources of healthcare reimbursement and about how these sources might be used to pay for music therapy, as well as a step-by-step guide to obtaining reimbursement. The symposium includes a 42 minute audio discussion as well as supporting text. The audio discussion covers the following topics:
1. Medicare, including partial hospitalization, prospective payment system (PPS), and minimum data set (MDS)
2. Medicaid, including information about approved providers and waivers
3. Private insurance
4. Other payers, including Worker’s Compensation and TRICARE
5. Coding systems and forms, including Current Procedural Terminology (CPT)®, Healthcare Common Procedure Coding System (HCPCS), International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9), Health Insurance Portability and Accountability Act (HIPAA), National Provider Identifier (NPI), and CMS 1500 Health Insurance Claim Form
6. Step-by-Step Guide for Obtaining Reimbursement
Click on the gray arrow below to listen to the audio discussion.
NOTE: The written materials below support the audio discussion for the March, 2009 AMTA.Pro on-line symposium. Scroll down to read (1) background about reimbursement issues, (2) a transcript of the audio discussion, and (3) a list of resources related to this topic.
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With healthcare costs growing annually and a national focus on the need for major healthcare reform, it is easy to understand why music therapy reimbursement is a significant issue for our profession. In order to obtain coverage for quality services, music therapists must learn some basic information about the insurance industry.Understanding how both private and public third party payers approach the process will improve opportunities for successful music therapy reimbursement.
AMTA has long acknowledged the importance of reimbursement through its publication of various resources and guides beginning in 1990. In the past decade, reimbursement was highlighted even more with the establishment of the AMTA Strategic Plan Reimbursement Priority. In its continuing efforts to further the association mission of advancing public knowledge of music therapy benefits and increasing access to quality music therapy services, the AMTA Executive Board selected reimbursement as a strategic priority and then implemented an operational plan initiative. The plan’s reimbursement and financing primary goal was to increase access to music therapy services by increasing the percentage of music therapy services receiving reimbursement.
From the first Reimbursement Guide for Music Therapists: Phase One (1990), to Music Therapy Reimbursement: Best Practices and Procedures (2004), there is evidence that more music therapists are seeking third party coverage and more music therapy services are receiving payment from those reimbursement sources.
Despite the increased success in receiving coverage for certain applications of music therapy in recent years, we continue to be presented with barriers such as tightening state and federal budgets, rising healthcare costs, and lack of state recognition of music therapy credentials. Acknowledging the logistical challenges that continue to exist, AMTA is actively pursuing advocacy opportunities that will help achieve the goal of increased reimbursement. In 2005, AMTA’s State Recognition Operational Plan – a collaborative project with CBMT – began addressing the issue of state recognition of the MT-BC credential. The project that will hopefully have a positive impact on music therapy reimbursement efforts.
The healthcare environment becomes more complex each year, making it essential for music therapists to stay up-to-date on the latest developments. The tools needed to succeed in today’s market are complex, sometimes requiring therapists to spend as much attention to the business of music therapy as to the clinical applications of music therapy. This symposium reviews music therapy reimbursement facts and step-by-step strategies to help clinicians, educators and students develop a better understanding of this important topic and its impact on practice.
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Welcome to AMTA.Pro, a benefit exclusively for members of the American Music Therapy Association. This symposium, released in March 2009, focuses on music therapy reimbursement. We will review primary sources of reimbursement and the steps required when seeking coverage for music therapy interventions. My name is Judy Simpson.
As music therapists, we have grown accustomed to hearing the questions,
“Music therapy…what’s that?”
“What exactly does a music therapist do?”
“What kind of music do you use?
We learn early on how to respond to these questions and our responses vary depending upon the audience and how much time is available to provide the most concise answer.
A change has occurred, however, in recent years, as more people become familiar with the concept of music therapy. With more public attention and increased awareness of the potential benefits of music therapy across various healthcare and educational settings, the questions are becoming more specific and require more detailed answers.
For example, when presenting proposals to offer music therapy services to a hospital, skilled nursing facility, or school, you’ll most likely not hear, “What’s music therapy?” but instead, you’ll probably hear,
“We would love to add music therapy to our program, how do we pay for it?”
“Do you receive reimbursement from Medicare and Medicaid?”
“Can you bill private insurance for your services?”
Discovering potential ways to reimburse music therapy services through public and private third party payment systems has really become a critical component to the business of music therapy. In order for us to be successful in our work, we must demonstrate an understanding of the current healthcare market, the insurance industry, and where music therapy fits within this environment.
Although this brief podcast won’t be able to cover all there is know about reimbursement, it will hopefully help you develop a basic understanding of the process as well as learn what resources are available to you for additional information. First I’ll focus on sources of reimbursement and how music therapy is currently covered by each source. Second, I’ll discuss the coding systems and forms that are used in the reimbursement process. Next, I’ll review some of the steps that are recommended when you are seeking coverage from a private insurance company. And finally, I’ll provide resources for you to explore for more detailed information on this subject.
Let’s start with Medicare. Medicare is the nationwide health insurance program that is administered by the Centers for Medicare and Medicaid Services, usually referred to as CMS. Individuals with Medicare include persons aged 65 and over, persons with disabilities, and persons with end-stage renal disease. There are many aspects to the Medicare program, and we usually hear them referred to by letters, Parts, A, B, C, and D, with each Part focused on a different area of coverage.
Because Medicare is such a large part of our nation’s healthcare program, many people want to know if Medicare covers music therapy and if so, how do we access that funding?
Music therapy can be considered a covered service under Medicare, but only in select situations.
A. Partial Hospitalization. The first example is if a healthcare facility offers a Partial Hospitalization Program or PHP as a part of its psychiatric service, music therapy can be included as a covered service. When a facility bills Medicare for each client in a PHP program, it uses a special code called a Healthcare Common Procedure Coding System or HCPCS to document that music therapy services were provided. This HCPCS code is G0176. The music therapist does not receive direct payment from Medicare, but the facility receives funding from Medicare, which is then used to pay the music therapist’s salary.
B. Prospective Payment System (PPS). The second example of how music therapy services can be covered is through the Medicare Prospective Payment System or PPS. Medicare PPS sets the rate of payment to a facility in advance for the coming year. So in other words, Medicare decides in 2009 what it will pay a facility to treat each type of diagnosis for 2010. Facilities are paid these rates for services regardless of the actual cost of these services.
For example, if a patient enters the hospital for treatment after having a stroke, Medicare will pay a certain dollar amount per day for a certain number of days, no matter how long a patient is actually in the hospital and regardless of how much it actually costs to provide services to that patient. Each facility then decides what it wants to offer for that set dollar amount. Although music therapy does not receive direct reimbursement from Medicare for services provided, music therapists can be included as part of the package that is covered under the PPS.
This is where music therapists must “sell” themselves to facilities as a cost-effective option. Some of the cost saving measures that help “sell” music therapy as part of the PPS package is when we are able to document:
increased patient motivation to participate in therapy
improved mood, and in turn, improved response to treatment
reduced reliance on and/or reduced dosage levels of pain medication and/or anesthesia due to enhanced coping and relaxation skills
decreased length of stay due to more rapid outcome achievement
In addition to general hospital settings, Medicare PPS has been implemented in most settings which employ music therapists, including skilled nursing facilities/nursing homes, hospice programs, and in-patient rehab settings. So even though we do not bill Medicare directly in these settings, we can be a part of the treatment team which is reimbursed through the pre-determined PPS.
C. Minimum Data Set (MDS): The final example of impacting Medicare reimbursement is in facilities which utilize the Minimum Data Set Assessment or MDS. This extensive assessment tool has many sections in which music therapists can provide input to the treatment team but not all sections of this document have an impact on the reimbursement a facility receives from Medicare. On the current version of this assessment called the MDS 2.0, music therapists can document minutes under Section P3, Restorative Care. This program usually is managed by nursing and in many facilities, CNAs or certified nurse assistants facilitate this program. Some facilities, however, do not have the necessary staff that is trained to offer this service and as a result, these facilities turn to recreation therapy and music therapy for programming assistance.
Restorative Care is designed for those clients who are not involved in active physical or occupational therapy programs. It is designed more for those individuals who are long term residents needing assistance to restore as much independent functioning as possible to enhance their daily living. Not all residents in a facility using the MDS will qualify for Restorative Care programming. This decision is usually made by the treatment team.
Several programs that music therapists typically provide in skilled or residential care facilities may fall under Restorative Care. Exercise programs, socialization groups, and orientation sessions are a few examples of interventions that might help to address Restorative Care needs of clients. The best way to explore this option of documenting music therapy under the Restorative Care section of the MDS is by collaborating with the MDS coordinator in a facility.
Please remember that music therapy can not bill Medicare directly for services, but instead, can provide and document services under the existing Restorative Care section of the MDS. When quality services are provided and documented under this heading, the facility in turn, receives more reimbursement from Medicare. In other words, the facility receives an additional amount of funding on top of the flat daily PPS payment.
In AMTA’s recent communication with CMS regional offices across the country, we have learned that is not possible to determine the exact amount of additional reimbursement a facility receives when Restorative Care programming is offered. This is due to a variety of complex factors involved in the Prospective Payment System (PPS), such as the Case Mix Index and RUGs or Resource Utilization Groups. If you are interested in learning more about these details of reimbursement in facilities that use the MDS, references and resources are provided in the printed handouts of this symposium.
One positive item to mention is that the MDS 2.0 has been going through a revision process for the past several years; and thanks to the advocacy of AMTA members, the current draft MDS 3.0, expected to be implemented in late 2009, has a section to document music therapy minutes. Although we are not yet certain of the actual impact this will have on reimbursement in facilities using the MDS, it is a positive step in justifying the inclusion of music therapy programming. To stay up-to-date on developments with the MDS, please refer to issues of Music Therapy Matters, AMTA’s online quarterly newsletter.
Medicaid, or Title XIX of the Social Security Act, was established in 1965 as an insurance program that is co-financed by the federal and state governments, and administered by the states. It is the largest state-based payer of health care services for low-income citizens. Federal law outlines the basic Medicaid program that all states must provide. Rules regarding eligibility, covered services, participant protections, and implementation are standard throughout all 50 states. Since Medicaid is partially funded by the federal government, these basic federal requirements must be met in order for states to continue receiving these funds. What makes Medicaid so complex, however, is the fact that the federal law also provides options for the states as they implement this program. As each state operates its own programs, it sometimes expands eligibility, increases the number of covered services, and administers the program differently.
A. Approved Providers. When we think of Medicaid, we often divide it into two types: core Medicaid and Medicaid waivers. Core Medicaid includes the basic services outlined by federal law. The funds are very restrictive and difficult for music therapists to access. For a music therapist to become an approved provider under the core Medicaid program usually requires additional education and qualifications, such as mental health counseling or social work.
B. Waivers. Medicaid waivers are programs developed by each state that focus on specific client groups or diagnoses and provide additional services that are not covered by other funding sources. Although each state can create a variety of waiver programs, there are three basic types of Medicaid waivers: freedom of choice waivers, home and community- based care waivers, and demonstration waivers. Typically, home and community-based care programs are developed to serve individuals who would require placement if services provided through the waiver were not available. In other words, the services funded through the waiver are assisting these individuals remain in their homes and achieve a level of functioning that helps to prevent outside placement. There are currently a few states that allow payment for music therapy services through use of Medicaid Home and Community Based Care waivers with certain client groups.
Addressing the addition of music therapy within existing Medicaid waiver programs is one part of the AMTA and CBMT state recognition operational plan. Networking with colleagues within your state is the best way to find out more information about possible access to these funds. For those states with established task forces or state associations, leaders within these groups are also great resources for the latest developments regarding various waivers in your state.
IV. Private Insurance
When reviewing all potential funding sources, music therapists have had the most success in receiving reimbursement from private insurance companies. Companies like Blue Cross Blue Shield, United Healthcare, Cigna, and Aetna have all paid for music therapy services at some time. Success has occurred on a case-by-case basis when the therapist implements steps within the reimbursement process and receives pre-approval for music therapy services.
Obviously we would prefer that music therapy be considered a covered service under private insurance plans without the need for case-by-case approval, but that level of global coverage is not currently available to music therapy. The criterion for obtaining general insurance coverage requires an extensive analysis by the third party payer of the supportive evidence and clinical protocols established for healthcare interventions. Our profession is still defining these areas. An example of how AMTA is tackling a specific area critical to advancing reimbursement efforts is through the research strategic priority. This priority and its operational plan were developed to address the direction of research in support of evidence-based music therapy practice and improved workforce demand; and to recognize and incorporate, where necessary, federal, state and other entity requirements for evidence-driven research as it relates to practice policy and reimbursement.
Until that time when music therapy is accepted as a general covered service, we must follow the recommended steps common to all healthcare procedures seeking reimbursement.
V. Other Payers
A. Workers’ Compensation. Workers’ Compensation insurance coverage provides employees who are injured or disabled on the job the healthcare services they need with the intent of avoiding any legal action. Each state has departments or divisions that oversee workers’ compensation issues. The actual insurance is usually provided through private insurance companies that also offer traditional health care plans.
As states attempt to contain the costs associated with workers’ compensation, many of these programs are now provided through managed care plans from the private insurance market. Requiring pre-approval before services can be offered and working with case managers are common among workers’ compensation programs. Some music therapists have received reimbursement from this type of coverage, specifically in the treatment of traumatic brain injury (TBI), physical rehabilitation, or pain management.
B. TRICARE. TRICARE is the nationwide Department of Defense (DOD) managed care program that is designed to ensure high-quality consistent health care benefits; preserve beneficiaries’ choice of health care providers; improve access to care; and contain health care costs. Access to this funding is rare, but some music therapists have reported successful reimbursement from this payment source.
VI. Coding Systems and Forms
Regardless of the reimbursement source, every music therapist needs to be aware of the coding systems and forms that are required within the insurance industry. I’ll review the primary codes and forms as well as provide resources where you can learn more of the details related to these important reimbursement tools.
A. Current Procedural Terminology (CPT®). CPT® is a systematic listing and coding of procedures and services performed by physicians, and other healthcare professionals in clinical practice. This coding system, developed by the American Medical Association (AMA), can be found in the CPT® Standard/Professional Edition manual, available for purchase through the American Medical Association at www.amabookstore.com. The manual is updated each year and prices for the 2009 editions range from approximately $75 to $100. As a member service, AMTA members can access a copy of CPT® codes successfully utilized by music therapists on the members-only section of the website.
For every therapeutic procedure implemented, clinicians submit a specific CPT® code that accurately identifies the service being performed. Each code, consisting of a 5 digit number, is then reported on the billing forms required by the insurance company. Third party payers then reimburse for services rendered based on a pre-determined dollar amount per CPT® code. These codes sometimes designate distinct time limits, frequently in fifteen-minute blocks. For example, if a therapist is performing a specific service for one hour, then that code number would be reported “x 4” and the rate associated with that code would be multiplied four times. In one therapy hour, a therapist may use two or three different codes, and each code may be assigned a different dollar amount by the insurance company.
Based on member survey information, there are insurance companies that are reimbursing for prescribed music therapy services once certain CPT® codes have been approved by an insurance company case manager. In order to secure reimbursement, it is recommended that CPT® codes be approved prior to rendering the service. An important step in seeking coverage is for music therapists to communicate with a clients’ case manager and these professionals serve as primary decision makers for determining approval for a certain service or CPT® code.
An important thing to remember about CPT® codes is that the codes are not discipline specific and are also used by related healthcare professionals (i.e., physical, occupational, speech, and recreational therapy). It is advised that you not submit bills using the same codes as another discipline for treatment on the same day as that might be considered by third party payers to be duplication of services. Even though the interventions are different, the procedure codes are broadly defined and could be interpreted by someone processing the claim to be repetition of service. It is extremely important to communicate with other therapists involved in the client’s treatment in order to follow proper billing procedures.
B. Healthcare Common Procedure Coding System (HCPCS). HCPCS codes are developed by the Centers for Medicare and Medicaid Services (CMS) and are considered the primary codes for Medicare and Medicaid billing. The only HCPCS code used to identify music therapy services is G0176. This HCPCS code is reported by partial hospitalization program billing departments when music therapy services are provided to Medicare beneficiaries. The code definition states, “Activity therapy, such as music, dance, art or play therapies not for recreation, related to the care and treatment of patient’s disabling mental health problems, per session (45 minutes or more).”
C. International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM). ICD-9 codes are used to identify diagnosis information. This coding manual includes a classification of diseases by diagnosis and each diagnosis is listed as an alphanumeric code. Since third party payers require documentation of “medical or behavioral necessity” to determine whether or not to reimburse a claim, it is important that the ICD-9 code reported on a claim form accurately reflect the medical reason why treatment is justified. Music therapists should consult with the referring physician or health care professional to determine which ICD-9 codes should be reported when billing for music therapy services.
Keep in mind, that each client may have multiple ICD-9 codes associated with his/her illness and/or disability. The first code listed identifies the primary diagnosis, condition, or problem. The second (and additional codes, if needed) code listed identifies coexisting conditions which may relate more to the reasons why the client is referred to music therapy. For example, a client’s primary diagnosis might be a cerebral vascular accident (stroke), but the secondary diagnosis might be aphasia and that is the problem that prompted the referral to music therapy.
D. Health Insurance Portability and Accountability Act (HIPAA). Most everyone is familiar with HIPAA and its requirements to maintain privacy and confidentiality of patient health records. For those of you interested in billing private insurance, it is recommended that you create your own HIPAA privacy notice for use in your clinical practice. Many third party payers may require that you submit signed copies of these documents from your clients in order to process billing claims. For more information and guidance on how to develop these forms, please refer to the Music Therapy Practice link on the members-only section of AMTA website.
E. National Provider Identifier (NPI). Another mandate from HIPAA was the creation of a standard identification system for all health care providers, facilities, and health plans to help with the billing processing. This system is called the National Plan and Provider Enumeration System (NPPES). The NPPES assigns National Provider Identifiers or NPIs to each provider through an application process that can be completed online.
Music therapists can apply and receive (at no cost) their individual NPIs for use in billing private and public third party payers. The link to the NPI application is available on the AMTA members-only section of the website under Reimbursement. On the application, music therapists are listed under “Respiratory, Developmental, Rehabilitative and Restorative Service Providers,” The application process takes approximately 20 minutes and you will probably receive your individual code within 2-3 weeks. Having the NPI will not guarantee reimbursement but having the NPI will allow you to identify yourself on billing claim forms.
F. CMS 1500 Health Insurance Claim Form. The CMS 1500 form is the standardized form used in Medicare billing and is also accepted and often required by many private insurance companies for individual reimbursement claims. Accurate completion of this form can make the difference between getting reimbursed and having a rejected claim. Music therapists can visit the CMS website, www.cms.hhs.gov and enter CMS 1500 in the search box for detailed information on how to complete this form. Keep in mind that some sections of this form will not require completion since you will be using it for private insurance claims. So even though the CMS website focuses on Medicare billing, the site also provides the guidance you need for filling in the correct information for private insurance claims. Special code numbers are required for some of the form’s sections and the CMS website provides the necessary code definitions for your review and selection. Small quantities of CMS 1500 forms can be ordered online from a variety of printing companies.
VI. Step-by-Step Guide for Obtaining Reimbursement
Now that you know the sources of reimbursement and the codes and forms you need to file a claim, lets’ review the recommended steps in the reimbursement process.
Step One: Obtain a referral for services. This referral can come from a physician, psychologist, social worker, case manager, parent, or client.
Step Two: Collect Insurance Information. In order to determine if music therapy services can be reimbursed, you will need to gather information about the client’s insurance plan, which can usually be obtained by making a copy of the insurance card. Make sure to document the group number, the member identification number, the name, phone numbers and address of the company. In addition, you will need to obtain the client’s full name, address, phone numbers, social security number, and date of birth.
This initial collection of personal information is also a time to present a copy of the HIPAA privacy notice for your practice and obtain signatures on the HIPAA notice as well as a release of information and an assignment of benefits form. These forms can be combined into one document, giving permission from the client for 1) you to talk with other providers and the insurance company about the client’s treatment; and for 2) the insurance company to pay you directly. As mentioned earlier, sample HIPAA forms are available on the members’ only section of the website and examples of the forms for gathering insurance information and assigning benefits are available in the 2004 AMTA Music Therapy Reimbursement book.
Step Three: Determine Client Needs. Before you contact the insurance company, you need to determine your client’s needs. Although you may wait to do a full assessment until after receiving notification that the insurance company will cover the fee, you need to at least conduct a brief initial assessment to determine if music therapy services are needed and justified. To make your case to the payer, you must outline the recommended scope, duration, and frequency of music therapy treatment. What issues will be addressed in music therapy? How many sessions per week and for how many weeks are necessary to reach treatment goals?
Why is music therapy medically or behaviorally necessary? This question is usually the most difficult to document and there are several ways you can address it. It is important to know that each insurance company defines medical and behavioral necessity differently, so if you can locate that definition on the company’s website, that will assist you in preparing to respond to this requirement. Basically, a general definition is that a treatment is considered necessary when you can document that if it wasn’t provided, it would have a negative affect on the client’s condition or the quality of care the client receives. Although the insurance company case manager will make the final determination about whether or not a service is medically/behaviorally necessary your assessment should justify the need for music therapy. Documentation of treatment needs along with specific plans and measurable goals is crucial.
Step Four: Prepare Marketing Materials. There are several items that can be a part of your arsenal of marketing tools. You won’t necessarily use them all in your first interaction with a payer but it’s best to have them available for reference and distribution. These materials include:
- a clear, basic definition of music therapy, which you can customize to address the specific client’s diagnosis
- an annotated bibliography of research related to the client’s diagnosis or treatment need
- the AMTA Reimbursement brochure which lists the numerous national entities that recognize music therapy as a valid treatment
- information from CBMT about the qualifications of a board certified music therapist, including the CBMT brochure, Scope of Practice, and Code of Professional Practice
- PR materials available from AMTA including the general brochures, fact sheets, article reprints, related publications, and website references
Step Five: Written order from physician. Contact the client’s primary care physician, neurologist, or psychiatrist, etc. and request a written order for music therapy. In some cases, music therapists have provided the physician with the selected CPT® codes that apply to the music therapy intervention so the order can also list the recommended codes. Obtaining the physician order does not guarantee evidence of medical or behavioral necessity but it does help to justify music therapy services to the payer.
Step Six: Obtaining coverage decision. Now that you have all these materials in hand, you can call the insurance company and request a coverage decision. Know that the first person you reach will be a customer service representative and will not be able to make that decision. Instead, please ask for a case manager to be assigned to the client so that a determination of coverage can be made based upon the client’s needs and the treatment outcomes you will address.
Step Seven: Obtain prior approval. Your goal in step seven is to obtain prior approval for the music therapy services. If you are able to talk with a case manager or other decision maker within the company, you may be able to obtain pre-approval during the first call. In talking with the case manager or company representative, present the referral, assessment findings, treatment goals, supportive research, music therapy overview, and your qualifications. Be prepared to provide justification of the treatment’s medical or behavioral necessity. Discuss the functional outcomes you will address and request pre-approval for treatment using appropriate CPT® codes that best describe the recommended music therapy procedures. Include in your request the number of sessions and corresponding time-line recommended. Offer to fax, e-mail, or mail supportive material to assist in the pre-approval process.
If you are unable to obtain verbal approval, kindly request the reason for denial. If you believe the decision might be reconsidered with additional supportive documentation, offer to provide more information. If approval is received, ask for the payment rate associated with the CPT® codes presented and determine if the rate is reasonable. If the reimbursement amount does not appear close to your standard rates, determine if the payment rates are negotiable. Request how often the company wants to be billed (i.e., after every session, after a certain number of sessions, or after all approved sessions are complete) and if they utilize the CMS 1500 form. Also during this discussion, be sure to ask how often they want updates. Document the name, title, department, address, phone, fax, and e-mail where these claim forms and updates must be sent.
Step Eight: Send confirmation letter. Once you have received pre-approval, it is very important that you send a confirmation letter or email which includes all the details discussed on the phone. Examples of pre-approval confirmation letters are available in the 2004 AMTA Music Therapy Reimbursement book.
Step Nine: Begin music therapy. Once you have received pre-approval confirmation, you can begin the music therapy interventions. Make sure to document all elements of the treatment including the
assessment, descriptions of the treatment, any cost savings for the patient due to involvement in music therapy, like reduced used of pain medications, effectiveness of the treatment and the functional outcomes achieved.
Reimbursement is successful when you present clear and accurate information, maintaining contact with the case manager and responding to all communication in a timely and professional manner.
Step Ten: Prepare claim form. Prepare the CMS 1500 claim form or whatever form the company instructs you to use, include all the required codes, such as CPT®, ICD-9, and your NPI, and submit the form to the payer. Although you may have a specialized invoice developed for your individual practice, you may only need to submit the standardized claim form.
Step Eleven: Follow-up with case manager. Follow-up with the payer by communicating with the case manager that approved treatment to extend your thanks for his/her assistance on your client’s behalf, noting progress and outcomes achieved. This is also an opportunity to offer your expertise for any future clients in their care who could benefit from music therapy.
Step Twelve: Dealing with denial. Even if all steps are followed diligently, don’t be discouraged if your claim is denied for some reason. This denial does not mean the process is finished. The business of insurance is just that, a business. Sometimes insurers use denials as a way to delay payments for services, which ultimately are reimbursed. You can appeal the denial and it’s always best to work with the client and family if this route is pursued. The insurance company most likely has a well defined appeals process that should be followed, but there are some standard questions you can ask of the individuals you already know on staff. Those questions include:
- What was the reason for denial?
- Who made the initial decision?
- Was it an MD?
- Was the reviewer a specialist in the field for the services he/she reviewed?
- What is the appeals process?
If in working with the family you decide to formally file an appeal, make sure to provide additional supportive information to assist with the decision, involve the referring physician and involve the client and their family when possible.
I realize that we have covered a lot of information in this symposium and you might be feeling a bit overwhelmed at this point. Don’t worry! Music therapy reimbursement does not have to be a cumbersome process. Remember the first time you led a session and that feeling of not really knowing what to expect? Attempting reimbursement for the first time may create those same feelings. But once you have implemented the recommended steps a few times, the process will become easier, will require less preparation time, and will hopefully become a regular part of your music therapy practice.
Again, I am Judy Simpson. You can contact me via e-mail at Simpson@musictherapy.org. I am currently the Director of Government Relations for AMTA. Prior to joining the AMTA national office staff, I worked in St. Louis for 17 years with clients of all ages in general hospital settings, developing music therapy programs in physical rehab, oncology, labor and delivery, psychiatry, respiratory ICU, and general medicine. Please feel free to comment on any aspect of this AMTA.Pro on-line symposium, Music Therapy Reimbursement.
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American Music Therapy Association
Music Therapy Reimbursement: Best Practices and Procedures (2004)
Certification Board for Music Therapists
Centers for Medicare and Medicaid Services (CMS)
CMS 1500 Form Manual
Centers for Medicare and Medicaid Services (CMS):
Department of Health and Human Service (HHS) Office for Civil Rights (OCR):
Code Manuals: (HCPCS, CPT®, ICD-9-CM)
American Medical Association
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Neither the American Music Therapy Association nor its Board of Directors is responsible for the conclusions reached or the opinions expressed in any of the AMTA.Pro symposiums.