Although elementary general music specialists teach students with a variety of exceptionalities every day (Chen, 2007; Hahn, 2010; Hoffman, 2011), many music teacher preparation programs do not adequately address exceptionality (Salvador, 2010). Articles regarding "strategies that work" appear perennially in the professional literature (e.g., Hammel, 2004), but these strategies have seldom been the subject of empirical research in peer-reviewed literature, and none of these articles pertain to how music teachers modify instruction to meet the needs of students with moderate to severe cognitive impairments (CI) who attend music with their self-contained categorical classes. This qualitative study details the practices of an elementary general music teacher with regard to music instruction of students with moderate to severe CI, both when these students were included with their fourth-grade peers and also when they attended music with their self-contained class.