Does medicare cover physical therapy after knee replacement

Physical therapy services

When your doctor or other health care provider (including a nurse practitioner, clinical nurse specialist, or physician assistant) certifies you need it, Medicare Part B (Medical Insurance) helps pay for medically necessary outpatient physical therapy. 

Your costs in Original Medicare

After you meet the

Part B Deductible

, you pay 20% of the 

Medicare-Approved Amount

.

Note:

There's no limit on how much Medicare pays for your medically necessary outpatient therapy services in one calendar year.

What it is

Physical Therapy is care that:

• Evaluates and treat injuries and diseases that change your ability to function.
• Improves or maintains current function or slows decline.

En español | Yes. Medicare covers physical therapy that’s considered medically necessary to treat an injury or illness, such as to manage a chronic condition like Parkinson’s disease or aid recovery from a fall, stroke or surgery. Medicare also covers:

• Occupational therapy, which helps with daily living activities, such as bathing, dressing and eating.
  
• Speech-language pathology, which provides evaluation and treatment to regain and strengthen speech and language skills.

What inpatient physical therapy does Medicare cover?

Medicare Part A covers inpatient stays in hospitals, skilled nursing facilities and some home care, as well as physical therapy at inpatient rehabilitation facilities. It may also cover in-home services if you’re eligible for home care or services you receive at a skilled nursing facility after a three-day hospitalization.

Your out-of-pocket costs, such as deductibles and coinsurance, depend on the treatment setting. For example, your share of the cost is different if you receive inpatient care in a hospital vs. a skilled nursing facility.

What outpatient physical therapy does Medicare cover? 

If you require skilled therapy services, Medicare covers outpatient therapy services, including occupational therapy, physical therapy and speech-language pathology. But your doctor or therapist must create and regularly review the care plan.

Medicare Part B will cover outpatient physical therapy once you pay the annual Part B deductible for doctor and outpatient services, which is $233 in 2022. You’ll also pay 20 percent of the Medicare-approved amount for outpatient occupational therapy, physical therapy and speech-language pathology received at:

• A doctor’s or therapist’s office.
• A hospital outpatient department.
• An outpatient rehabilitation facility.
• A skilled nursing facility if you’re being treated as an outpatient or are ineligible for a Medicare-covered stay.
• Home if a Medicare-certified home health agency provides care and you’re ineligible for Medicare Part A home health benefits. 

Keep in mind

Medicare previously set an annual maximum payment for outpatient therapeutic services but eliminated that cap in 2018. While the program no longer limits what it will pay yearly for medically necessary therapy, if your total therapy costs reach a certain amount within a year, your provider must confirm that the therapy is medically necessary. In 2022, that amount is $2,150 for physical therapy and speech language pathology combined, and $2,150 for occupational therapy. 

Updated September 13, 2022

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

Do I need a referral for physical therapy under Medicare?

Medicare only pays for physical therapy if a doctor refers you. It will not cover physical therapy if you are not under a doctor’s care.

Does Medicare cover physical therapy for back pain?

Medicare covers necessary physical therapy to help you manage back pain. Part B of Medicare would pay for this therapy unless you were recently hospitalized.

Does Medicare cover transportation to a physical therapist?

Medicare does not cover non-emergency transportation to doctors. But, some Medicare Part C plans may include transportation benefits.

Does Medicare cover aquatic physical therapy?

If your doctor states you would benefit from aquatic physical therapy, Medicare covers it. su_spoiler]

Does Medicare cover occupational therapy?

Medicare covers occupational therapy in the same way it covers physical therapy. Additionally, Medicare offers coverage for speech therapy.

Does Medicare provide coverage for CORF care?

Medicare covers Comprehensive Outpatient Rehabilitation Facilities (CORFs) services, including physical and occupational therapy.

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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.

To find the most suitable plan option for you, call us at the number above today! You can get a rate from all the top carriers in your area and find the best match. Fill out an online rate form to start now.

Jagger Esch is the Medicare expert for MedicareFAQ and the founder, president, and CEO of Elite Insurance Partners and MedicareFAQ.com. Since the inception of his first company in 2012, he has been dedicated to helping those eligible for Medicare by providing them with resources to educate themselves on all their Medicare options. He is featured in many publications as well as writes regularly for other expert columns regarding Medicare.

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