What Is the Medicare Therapy Cap for Physical Therapy?

Physical therapy is often used to reduce pain and improve or restore a person's mobility after an injury or health problem. People who receive health insurance through Medicare may wonder if physical therapy is covered, or if there is a limit to their coverage.

No Physical Therapy Services Cap

Previously, there was a Medicare therapy cap that limited how much Medicare would pay for outpatient therapy. In 2017, the cap was $1,980 for physical therapy and speech-language pathology services combined. However, Congress repealed the Medicare therapy cap in 2018, allowing more Medicare beneficiaries to be able to afford physical therapy and other services.

While the current Medicare law has removed the Medicare therapy cap for medically necessary outpatient therapy services, there are a few things to note. If your physical therapy and speech-language pathology services total $2,010 combined, your therapist will need to add a special code to your therapy claim to confirm that your services are reasonable and necessary, and that your medical record includes information that explains why these services are medically necessary. A medically necessary service is one that is needed to diagnose or treat an illness, injury, or condition.

Medicare patients typically receive physical therapy and other services to recover from injuries, medical procedures, or health emergencies like a stroke. It may also be used to help patients cope with disabilities or chronic conditions such as Parkinson's disease.

Orthopedic issues are another reason why many Medicare patients receive physical therapy. According to the Canadian Physiotherapy Association, manual and exercise therapy can improve joint mobility and strength, decrease pain, and restore physical function. It can also prevent future injury. For conditions such as osteoarthritis, physical therapy can reduce pain and stiffness while improving mobility. The use of physical therapy for osteoarthritis can also delay or eliminate the need for knee replacement surgery.

Original Medicare will cover 80 percent of the Medicare-approved amount for outpatient therapy services, and you will pay the remaining 20 percent.

Medically Unnecessary Services Aren't Covered

If your therapist plans to provide you with services that aren't medically necessary, he or she must give you an Advance Beneficiary Notice of Noncoverage (ABN) first. The notice allows you to choose whether or not you want the therapy services, with the understanding that you agree to pay for medically unnecessary services. This includes services that would generally be covered under Medicare but are not necessary or reasonable for you at the time.

Medicare beneficiaries who can benefit from physical therapy should note that their physician or health care provider may recommend services more often than Medicare covers. If this happens, be sure to ask questions about why the physician is recommending the services and if Medicare will pay for them. If not, you may be responsible for part or all of the costs for the services.

Physical therapy can help Medicare beneficiaries recover from injuries without the use of drugs or surgery. Be sure to talk to your health care provider to determine what services may be best for you.