The American Music Therapy Association estimates that at least 20% of music therapists receive third party reimbursement for the services they provide. Insurance companies are recognizing the advantages of including music therapy as a benefit as they respond to the increasing market demand for greater patient choice of health care services. Companies like Blue Cross/Blue Shield, Humana, Great West Life, Aetna, Metropolitan, and Provident have reimbursed for music therapy services.
Music therapy is comparable to other health professions like occupational therapy and physical therapy in that individual assessments are provided for each client, service must be found reasonable and necessary for the individuals’ illness or injury and interventions include a goal-directed documented treatment plan. Like other therapies, music therapy is typically pre-approved for coverage or reimbursement, and is found to be reimbursable when deemed medically necessary to reach the treatment goals of the individual patient. Therefore reimbursement for services is available in a large variety of health care settings with patients with varying diagnoses. Select individuals receive third-party reimbursement for music therapy services when deemed to be medically necessary by a physician’s referral. Reimbursement also may occur when music therapy is provided in conjunction with another service that is covered by insurance, such as speech therapy.
Medicare – Partial Hospitalization
Since 1994, music therapy has been identified as a reimbursable service under benefits for Partial Hospitalization Programs (PHP). Falling under the heading of Activity Therapy, the interventions cannot be purely recreational or diversionary in nature and must be individualized and based on goals specified in the treatment plan. The current HCPCS Code for PHP is G0176. The music therapy must be considered an active treatment by meeting the following criteria:
1. Be prescribed by a physician;
2. Be reasonable and necessary for the treatment of the individual’s illness or injury;
3. Be goal directed and based on a documented treatment plan;
4. The goal of treatment cannot be to merely maintain current level of functioning; the individual must exhibit some level of improvement.
Restorative Care Programs
Restorative care programs are traditionally supervised by nursing personnel and can be implemented by staff members who have the appropriate in-house training and orientation regarding resident care. The American Music Therapy Association validates that music therapists are qualified and able to contribute to these restorative care programs, documented on the MDS, which can positively affect a facility’s reimbursement from Medicare.
Several interventions and techniques that music therapists offer in skilled nursing facilities can be considered restorative care. When implementing restorative care programs, there are certain limitations that must be followed. There must be one staff member present for every 4 residents in the group identified as being on a restorative care program. If there are 10 residents participating in music therapy and only 4 are on restorative programs, only one staff member is necessary. If there are 10 residents in music therapy and between 5 to 8 individuals are on a restorative program, then there must be two staff members present. The second staff can be a CNA or student/intern, but the additional staff must also be trained in the facility’s basic resident care.
CPT Codes and Music Therapy
CPT (Current Procedural Terminology)
How do CPT codes pertain to music therapy? Currently, many case managers and insurance companies consider the CPT codes manual the reference of choice. The insurance company will reimburse for the therapy or service rendered based on a dollar amount per code. In addition, this code number may designate a fifteen-minute block of time. If a therapist is performing a specific service for one hour, then that code number would be used and the dollar amount multiplied times four. In one therapy hour, a therapist may use two or three different codes, and each code may be assigned a different dollar amount. Currently, there are insurance companies that are reimbursing for prescribed music therapy services once certain CPT codes have been approved by the case manager, utilization review director, or an insurance adjuster. In order to bill insurance companies for music therapy, CPT codes must be approved prior to rendering the service. The following are CPT codes which have been utilized by case managers and insurance companies, and which music therapists currently use to get reimbursed for their services. Related healthcare professionals (i.e. physical, occupational, speech and recreational therapy) use some of these CPT codes as well, and are successfully receiving reimbursement.
Code Title Descriptions
- 97110 Therapeutic Procedure, one or more areas, each 15 minutes Therapeutic exercises to develop strength and endurance, range of motion and flexibility
- 97112 Neuromuscular Re-education of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities
- 97113 Aquatic Therapy with Therapeutic Exercises
- 97116 Gait Training Includes stair climbing
- 97150 Therapeutic Procedure(s), Group (2 or more individuals)Group therapy procedures involve constant attendance of the physician or therapist, but by definition do not require one-on-one patient contact by the physician or therapist
- 97530 Therapeutic Activities (one-on-one), each 15 minutes. Direct patient contact by the provider (use of dynamic activities to improve functional performance)
- 97535 Self Care/Home Management Training, each 15 minutes Activities of daily living (ADL) and compensatory training, meal preparation, safety procedures, and instructions in use of assistive technology devices/adaptive equipment; direct one-on- one contact by provider
- 97537 Community/Work Reintegration Training, each 15 minutes. Shopping, transportation, money management, avocational activities and/or work environment/modification analysis, work task analysis; direct one-on-one contact by provider
- 97542 Wheelchair Management/Propulsion Training, each 15 minutes
- 97139 Unlisted Therapeutic Procedure Specify
- 97532 Development of Cognitive Skills (one-on-one), each 15 minutes. Improve attention, memory, problem solving, (includes compensatory training), direct patient contact by the provider
- 97533 Sensory Integrative Techniques (one-on-one), each 15 minutes. Enhance sensory processing and promote adaptive responses to environmental demands, direct patient contact by the provider
- 97799 Unlisted Physical Medicine- Rehabilitation Service or Procedure
- 96105 Assessment of Aphasia (per hour) Includes assessment of expressive and receptive speech and language function, language comprehension, speed production ability, reading, spelling, writing with interpretation and report
- 96110 Developmental Testing Limited with interpretation and report
- 96111 Extended Assessment (per hour) Includes assessment of motor, language, social, adaptive and/or cognitive functioning by standardized developmental instruments with interpretation and report
- 96115 Neurobehavioral Status Exam (per hour) Clinical assessment of thinking, reasoning and judgment (e.g. acquired knowledge, attention, memory, visual spatial abilities, language functions, planning), with interpretation and report
- 92506 Evaluation of Speech Evaluation of speech, language, voice, communication, auditory processing, and/or aural rehabilitation status
- 92507 Treatment of Speech; Individual Treatment of speech, language, voice, communication, and/or auditory processing disorder (includes aural rehabilitation)