You may wonder if your Medicare coverage includes physical therapy. Luckily, Medicare coverage for physical therapy is available when a physician recommends it.
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You will need physical therapy to get back on your feet in some cases. Whether you are in an accident or have a medical condition, physical therapy can improve your quality of life.
Medicare will cover the treatment if a doctor says that physical therapy is medically necessary after surgery or to treat a condition. Below, we will review when Medicare coverage applies, how often coverage applies, and what you should know before starting physical therapy treatment with Medicare.
Does Medicare Pay for Physical Therapy?
Medicare covers physical therapy when a physician deems it medically necessary. When physical therapy happens during or after hospitalization, Medicare Part A covers the cost. On the other hand, Part B of Medicare pays for outpatient or at-home physical therapy.
If you obtain physical therapy in a hospital, skilled nursing facility, outpatient physical therapy center, or home, you may be responsible for part of the cost.
Medicare Part A provides coverage for inpatient physical therapy. Medicare Part A will also pay for therapy in a skilled nursing facility after discharge if you are in the hospital for at least three days.
If your doctor prescribes physical therapy and you have not stayed at the hospital, Medicare Part B will cover the costs. However, deductibles and coinsurance still apply. So, be ready to pay a portion of the bills.
At-Home Physical Therapy and Medicare
If you qualify for home health benefits, you can have Medicare cover physical therapy at your home in full.
You must:
- Be under a doctor’s care
- Improve or maintain your current physical condition
- Have your doctor certify that you are homebound
In addition to in-home physical therapy, Medicare also pays a portion of the cost for durable medical equipment used during treatment.
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What are the Medicare Rules for Physical Therapy?
In the past, Medicare paid physical therapists based on the number of visits and time spent with patients. Since then, Medicare adopted a value-based approach to physical therapy to keep costs down and improve care. Physical therapy doctors are now paid based on a complex formula that considers several patients’ needs factors.
Doctors can authorize up to 30 days of physical therapy at a time. But, if you need physical therapy beyond those 30 days, your doctor must re-authorize it.
Medicare Physical Therapy Cap 2022
Until recently, Medicare had a cap on the number of physical therapy sessions you can have in a year. However, Medicare no longer enforces these physical therapy limits. Thus, you can have as much physical therapy as is medically necessary each year.
However, the threshold amount that Medicare pays for physical and speech therapy combined is $2,150 before reviewing a patient’s case to ensure medical necessity. Once you meet this threshold, Medicare will still cover physical therapy services. However, they must be billed with unique codes to prove medical necessity.
Does Medicare Cover Physiotherapy?
Physiotherapy is another term for physical therapy in many parts of the world, including Canada, Europe, and Australia. Some physical therapy doctors in the U.S. may use physiotherapy to describe what they do. If this is the case, Medicare will cover your therapy, whether it is called physical therapy or physiotherapy.
Medicare Part C and Physical Therapy
Medicare Part C or Medicare Advantage plans cover the same benefits as Original Medicare or better. So, you can expect Medicare Advantage to cover physical therapy.
When you enroll in a Medicare Advantage plan, cost-sharing expenses can vary between plans. Additionally, you will need to stay in-network to obtain proper coverage at the lowest cost.
Medicare Supplement Plans and Physical Therapy
Your Medicare Supplement (Medigap) policy could cover your out-of-pocket physician therapy costs. Depending on the Medicare Supplement plan, you could receive full coverage. Those who anticipate needing physical therapy should consider Medigap to keep their costs as low as possible.
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To better explain how Medigap could benefit someone in need of physical therapy, let’s look at an example. Suppose Josie needs physical therapy for her knees. She enrolled in Medicare Supplement Plan G because she knows she needs to visit the doctor’s office frequently.
Since Josie has Medigap Plan G, she will pay her premium and the Medicare Part B deductible. If Josie has inpatient physical therapy, she will not pay anything other than her monthly premium.
But, with outpatient physical therapy, Josie will need to pay the Medicare Part B deductible. If Josie did not have Medigap, she could be responsible for deductibles and coinsurance.
FAQs
How to Get Help Paying for Physical Therapy with Medicare
Physical therapy can make a huge difference in your healing process after an injury or illness, and it can help you manage chronic health issues. At MedicareFAQ, our agents understand the importance of having quality coverage.
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Sources:
MedicareFAQ is dedicated to providing you with authentic and trustworthy Medicare information. We have strict sourcing guidelines and work diligently to serve our readers with accurate and up-to-date content.
- Therapy Services, CMS. Accessed April 2022.
https://www.cms.gov/medicare/coding-billing/therapy-services - Physical Therapy, Medicare. Accessed April 2022.
https://www.medicare.gov/coverage/physical-therapy
My mom, age 101, started getting physical therapy at home when she could no longer travel to the company’s site. She fell last June, and since she returned home she has again been getting at-home PT.
The problem is, her provider repeatedly cuts her off. It says that they have to tell CMS when her improvement “plateaus.” Then we have to wait six weeks or so until her service restart.
The last time this happened was in July. This time, though, she lost the ability to walk (with her walker) at all. She’s been in sub-acute rehab since late August, has improved, and will be coming home in two days.
We obviously can’t have this. This experience proves beyond question that she must have PT to maintain her physical condition (i.e., the ability to walk with a walker). Yet the provider adamantly insists that it has to cut off services once she “plateaus.” Can you help us?
Hi Robert, I’m sorry to hear about your mothers condition. Unfortunately, we cannot help when it comes to diagnosis/decisions made by the doctor. Is there any way for you to receive a second opinion from another doctor or facility? A second opinoin may solidify this doctors decision, or change the perspective of her care.
A person does not need a referral to go to physical therapy, but I am told that for PT to get paid, a referring doctor must sign off on referral? That is confusing.
Please explain.
Sharon, this would depend on the plan you have. Are you on Original Medicare or Medicare Advantage?
Our physical therapist recommended arm massage after complete shoulder replacement surgery would that be covered by medicare if provided by the PT office? How do we make sure what they’re doing is covered by Medicare so we don’t get any surprise bills? Thanks for any info you can provide.
Mark, any physical therapy required due to surgery should be covered by Medicare. It would be best to speak with your PT and ask if the service is regularly covered for Medicare beneficiaries.
Can a qualified MD who has opted out of Medicare refer a Medicare patient to physical therapy?
Angie, yes, any qualified physician can refer a patient to a specialist, however, Medicare will not provide payment to a doctor who is not contracted with them.
Hi Jagger, if I rec’d a denial from Medicare for PT benefit max can I appeal with GP KX modifier? I am confused if there is no cap why they are getting denied.
I pray you answer. Have a great day
Hi Stephanie, please talk to your physician. The maximum amount is only for the purpose of evaluating medical necessity.
I was told by the nurse practitioner at my Orthopedic doctor’s office that Medicare requires I attend doctor prescribed outpatient physical therapy for my back pain before I could have an MRI to check further the cause of my back pain. If this is true, can you tell me how many PT sessions I must attend before I qualify to have an MRI administered to me by my Orthopedic doctor?
Hi Sydney – we would recommend asking your doctor themselves about this. However, it is usually the other way around and some patients are told to have MRIs before attending physical therapy.
Hello Jagger,
I’m a Part B provider for PT and OT. What’s the limit for PT and OT for 2021 that Medicare will cover.
Thanks,
Christine
Hi Christine, thank you for your question. There is no limit as long as the services are medically necessary. However, there is a threshold for review once a patient reaches $2,110 for physical therapy and speech language pathology services combined. There is also a separate $2,110 threshold for review for occupational therapy. These amounts are subject to change each year.
Does the office visit copay apply for Plan N for physical therapy?
Hi Jane, most of the time, you will owe a $20 copay for office visits with Plan N. However, whether you owe the copay will depend on the billing code for your service.
I fell just over 2 months ago. I broke 5 vertebrae and had a kyphoplasty on the 3 that needed them. I still had persistent pain and the MRI of my lumbar spine showed significant arthritis just below my kyphpplasty done to L1.
I can’t take NSAIDS because of my Crohn’s disease.and a month of physical therapy has not improved it.
My doctor wants to continue with medial lumbar injections. I was told that pre authorization and upon investigating this found that they would not approve until I have a record of pain for 3 months.
Is there a cap for paid number of therapy visits under part B?
Hi Ryan! Great question. No, there is no cap or limit for the paid number of therapy visits under Medicare Part B.