Medicare guidelines for physical therapy documentation 2022

After you meet your Part B deductible, Medicare will cover 80 percent of medically necessary physical therapy costs,  with no limit on outpatient physical therapy coverage. Medicare can cover physical therapy at home, in skilled nursing facilities, and in outpatient rehabilitation facilities.

Physical Therapy and Medicare Coverage

Medicare Part A

Medicare Part A can cover some of the cost of physical therapy at either an inpatient facility or your home. The longevity of the treatment as well as your deductibles and other payments are taken into consideration when calculating the overall costs for physical therapy coverage. Keep in mind that Medicare will only pay for services that are “reasonable and necessary.” Medicare Part A covers inpatient stays at settings such as rehab centers or skilled nursing facilities. Additionally, it can also cover hospice care.

Medicare Part B

Since there are no annual caps, Medicare Part B covers medically necessary services that are certified by a doctor or physical therapist. This could include outpatient therapy, occupational therapy, physical therapy, or other forms of therapy in an outpatient setting to alleviate, treat, or prevent conditions. Care can be administered at skilled nursing facilities or provided at home or other outpatient facilities.

Medicare Advantage

Most Medicare Advantage or Medicare Part C plans provide additional coverage that other parts of Medicare (Parts A and B) might not typically cover. For example, Medicare Advantage can cover physical therapy so long as you pay the 20 percent after you meet your Part B deductible, which is $203 in 2021. If your physical therapy is not medically necessary, you will have to pay the full cost of the treatment.

Medigap

Medigap, or Medicare supplemental insurance, covers the cost that might not be covered by Parts A and B. You may want to check with your plan to see what’s covered and what you’d have to pay out of pocket. Medigap plans will always cover what Medicare covers, including the 20 percent coinsurance. Some plans will even pay your Part B deductible.

Medicare and the Costs of Physical Therapy

The costs of physical therapy vary depending on your Medicare coverage, but it can range between $75 to $350 per session (out of pocket). Fortunately, there are many ways to ease the financial burden if you qualify for coverage through Medicare.

Medicare Coverage

The good news is there’s no limit on the number of physical therapy treatments within one calendar year as long as your physician or physical therapist can certify that treatment is medically necessary.

In terms of Medicare coverage, Part B helps pay 80 percent of medically necessary outpatient physical therapy. You’d essentially be responsible for 20 percent plus the deductible for Part B. However, the total amount may vary, so be sure to check whether your provider is enrolled in Medicare, what type of treatment you are receiving, and whether you might have other insurance.

Under Part B, you can receive services for physical therapy, speech-language therapy, and/or occupational therapy, depending on what your physician or physical therapist deems medically necessary. Eligibility for Medicare coverage for outpatient physical therapy services varies, but your physician must certify that it is medically necessary.

Medigap and Copays

Medigap covers the gaps in Original Medicare. Check with your plan and provider to see whether Medigap can cover out-of-pocket costs for services related to physical therapy.

Medicare and Physical Therapy Frequently Asked Questions

• How many days of physical therapy will Medicare pay for?

  Medicare doesn’t limit the number of days of medically necessary outpatient therapy service in one year that it will pay for.

• Does Medicare cover physical therapy?

  Yes, Medicare covers either partial or full physical therapy, depending on your situation and eligibility.

• Can Medicare deny physical therapy?

  Yes, if there is no documentation by a physician or physical therapist that deems that the services are medically necessary, Medicare will deny coverage for physical therapy. Medicare will move forward with a claim only if a licensed physician authorizes the services.

• What is the Medicare physical therapy cap for 2021?

  The Medicare physical therapy cap for 2021 is $2,110. If you exceed that amount, your physician or physical therapist must certify and provide documentation that your care is medically necessary.

• Will Medicare pay for physical therapy without a referral?

  You don’t need a referral for physical therapy, but Medicare won’t pay for services unless the provider is approved by Medicare.

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