How to Get Medicare to Pay for Continuing Physical Therapy

You can access your physical therapy benefits through Original Medicare or your Medicare Advantage Plan. Medicare no longer limits how much physical therapy you can get but requires ongoing written evidence that it is still helpful and necessary for you.

You can receive physical therapy in an inpatient setting like the hospital or a skilled nursing facility, or an outpatient setting like a therapist's clinic. You may be eligible to receive physical therapy at home as part of your home health care services or as an outpatient service. Physical therapy is covered under Medicare Parts A and B, as long as it is prescribed by a physician or non-physician practitioner and is deemed medically necessary to treat your condition.

Why is Physical Therapy Valuable?

According to the American Physical Therapy Association (APTA), physical therapy can help you regain or maintain your ability to move and function after injury or illness. Physical therapy can also help you manage your pain or overcome a disability. Physical therapists are specially trained and licensed to prescribe exercises, provide education, and give hands-on care to you in various settings.

Does Medicare Cover Physical Therapy?

Medicare covers physical therapy as a skilled service. Whether you receive physical therapy (PT) at home, in a facility or hospital, or a therapist's office, the following conditions must be met:

• PT must always be medically necessary for Medicare to provide coverage. That means it is a treatment for your condition that meets accepted standards of medicine.
• There must always be a physician's or non-physician practitioner's (like a physical therapist) order to certify you need to start PT.
• You must have an ongoing medical need for PT to continue.
• You must receive PT from a provider who participates in Medicare.

Medicare will cover physical therapy under either Original Medicare Part A or Part B, or a Medicare Advantage Plan. Your coverage and how much you pay depends on your plan, your particular circumstances, and where you receive your therapy.

Several conditions must be met for Medicare to cover your physical therapy. The burden of proof that you are eligible to receive your physical therapy benefits lies with the suppliers and providers of therapy. There are rules about billing codes and documentation that the facility, therapist, or agency must follow. Medicare Part A and Part B cannot be billed at the same time. Make sure you understand what your coverage looks like and how much you may need to pay, especially if you receive physical therapy in different settings.

What Parts of Medicare Cover Physical Therapy?

Part A (hospital insurance) covers physical therapy as an inpatient service in a hospital or skilled nursing facility (SNF) if it's a Medicare-covered stay, or as part of your home health care benefit. You are responsible for the Part A deductible for your hospital inpatient stay ($1,556 per benefit period in 2022) and a daily coinsurance if you are in a SNF longer than 20 days. There is no copay for physical therapy as part of your home health care benefit under Part A.

For instance, suppose you are in the hospital after surgery or after being treated for an acute illness like pneumonia. As you recover, physical therapy may be part of your treatment plan to ensure that you continue improving and functioning well once you are back home. Your physical therapist will provide hands-on care, education, and specific exercises you can do at home.

Sometimes, you will go directly home from the hospital and may continue to receive physical therapy services as part of your home health care benefit. Or, you may go to a Skilled Nursing Facility (SNF) from the hospital to continue your rehabilitation and recovery before you go home.

Does Medicare Cover In-home Physical Therapy?

Medicare Part A covers in-home physical therapy as a home health benefit under the following conditions:

• Your physician must certify the physical therapy services as medically necessary.
• Physical therapy is part of your home health plan of care that details how many visits you need and how long each will last.
• Your plan of care must be reviewed and renewed (if appropriate) at least every 60 days.
• A qualified homebound therapist provides services.
• You must be homebound; that is, you can only leave your home with considerable difficulty and require assistance to do so.
• You must receive your home health services, including physical therapy, from a Medicare-approved home health agency.

Medicare Part B covers in-home physical therapy as an outpatient or preventive service in the same way it covers physical therapy in an office or clinic. Services must still be medically necessary, but the benefit of home visits is that the physical therapist can evaluate you and prescribe exercises that apply to your home environment. You are not required to be home-bound as with Part A, but all other rules and restrictions apply.

What Are the Medicare Caps for Physical Therapy Coverage?

Medicare no longer caps medically necessary physical therapy coverage. For outpatient therapy in 2022, if you exceed $2,150 with physical therapy and speech-language pathology services combined, your therapy provider must add a modifier to their billing to show Medicare that you continue to need and benefit from therapy.

What drives whether or not Medicare will continue to help pay for your physical therapy is its effect on your condition and ability to function without pain or decline. You may receive physical therapy as an inpatient service covered by Part A or an outpatient, preventive service covered by Part B. It is up to the therapist, facility, or agency to bill Medicare using the correct billing codes. Medicare requires documentation that shows your progress and needs for ongoing therapy.

Certified Senior Advisor (CSA)^®

As a health care professional since 1987, Kelly Blackwell has walked alongside and cared for seniors as they journey through the season of their fourth quarter of life. Blackwell holds a Bachelor of Science in nursing from the University of Northern Colorado, a Master of Science in health care administration from Grand Canyon University, an interprofessional graduate certificate in palliative care from the University of Colorado Anschutz Medical Campus and holds a Certified Senior Advisor^® credential from the Society of Certified Senior Advisors.

Blackwell contributes to the University of Colorado-Anschutz blog and has been published in "The Human Touch" distributed by the University of Colorado Center for Bioethics and Humanities. She cowrote "Dying Is" for Pathways Hospice.

A registered nurse, Blackwell understands health insurance choices influence quality of life and are driven by values, goals, and beliefs. She's passionate about engaging with, educating, and empowering seniors as they navigate the health care system. She's equipped to lend an experienced, compassionate voice to beneficiaries seeking information about Medicare Advantage Plans.

As a CSA^®, Blackwell has access to valuable resources for Medicare beneficiaries. Her work as a bedside nurse and clinical manager has given her the opportunity to see how Medicare rules, regulations, and benefits work when patients need them. With a passion to learn and to make a difference in the lives of seniors, Blackwell supports seniors through Medicare and fourth-quarter life decisions.

Learn More From Our Sources

• CMS | 2021 Annual Update of Beneficiary Threshold Amounts | Last accessed October 2022
• APTA | What Physical Therapists Do | Last accessed October 2022
• Medicare | Physical Therapy Coverage | Last accessed October 2022
• Medicare | Medicare Home Health Services | Last accessed October 2022
• Medicare | Medicare and You Handbook 2022 | Last accessed October 2022
• Medicare | Skilled Nursing Facility Care Coverage | Last accessed October 2022

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Source: https://www.medicareplans.com/does-medicare-cover-physical-therapy/

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