Saturday, September 23, 2023

Does Medicare Cover Outpatient Physical Therapy

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Using The Kx Modifier

Medicare Physical Therapy Coverage Two Providers

Add the KX modifier to claim lines to indicate that you are attesting that services at and above the therapy thresholds are medically necessary, and that documentation in the patient’s medical record justifies the services. This includes documentation that patients, based on their condition, require continued skilled therapyie, therapy beyond the amount payable under the threshold to achieve their prior functional status or maximum expected functional status within a reasonable amount of time.

You do not need to submit special documentation along with the KX modifier threshold. You are responsible for consulting guidance in the Medicare manuals and professional literature to determine if the beneficiary qualifies for the exception.

Note that while this process is “automatic,” your submission is not binding on the Medicare contractor, who makes the final determination on whether the claim is payable.

In making a decision about whether to use the KX modifier, consider, for example, whether services are appropriate to:

  • The patient’s condition, including the diagnosis, complexities, and severity.
  • The services provided, including their type, frequency, and duration.
  • The interaction of current active conditions and complexities that directly and significantly cause the treatment to exceed the therapy threshold.

Does Medicare Cover Exercise Programs

Exercise programs have a lot of benefits to them. Not only can you shed some extra pounds, but exercise provides countless other benefits both physical and mental. However, despite their health benefits, exercise isnt technically a healthcare treatment.

Which leads to a common question a lot of people wonder aboutdoes Medicare cover exercise programs? In this article, we answer that question in clear, plain English.

Medicare Advantage Plans Also Cover Rehab

Medicare Advantage plans are required to provide the same benefits as Original Medicare. Many of these privately sold plans may also offer additional benefits not covered by Original Medicare, such as prescription drug coverage.

This means that a Medicare Advantage plan will pay for your qualified rehab in the same ways that Medicare Part A and Part B would. You could potentially find a Medicare Advantage plan that also offers other benefits that you find helpful but arent covered by Original Medicare.

Find Medicare Advantage plan benefits in your area

Or call 1-800-557-6059TTY Users: 711 to speak with a licensed insurance agent. We accept calls 24/7!

About the author

Christian Worstell is a licensed insurance agent and a Senior Staff Writer for He is passionate about helping people navigate the complexities of Medicare and understand their coverage options.

His work has been featured in outlets such as Vox, MSN, and The Washington Post, and he is a frequent contributor to health care and finance blogs.

Christian is a graduate of Shippensburg University with a bachelors degree in journalism. He currently lives in Raleigh, NC.

Where you’ve seen coverage of Christian’s research and reports:

Plan availability varies by region and state. For a complete list of available plans, please contact 1-800-MEDICARE , 24 hours a day/7 days a week or consult

Medicare has neither reviewed nor endorsed this information.

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Who Is Eligible For Physical Therapy Under Medicare Insurance

If you have Medicare Part B your physical therapy costs will be coveredas long as Medicare finds the treatment medically necessary.

Medicare considers physical therapy treatment medically necessary if it meets the following requirements:

  • Therapy is needed to diagnose or treat an illness or condition.
  • The treatment meets accepted standards of medicine.
  • Your doctor confirms therapy is necessary to treat your condition.

Most people who qualify for Medicare Part B insurance do so based on their age of 65 older. But you could also qualify if you meet at least one of the following requirements:

  • You are disabled and have received Social Security Disability Income for two years.
  • You have Amyotrophic Lateral Sclerosis , also known as Lou Gehrigs disease.
  • You have End-Stage Renal Disease .

Learn more about who qualifies for Medicare.

Medicare Advantage plans also cover physical therapy, since they are required to cover everything Medicare Part A and Part B cover. There may be additional benefits with some Medicare Advantage insurance plans, and your costs may differ from Original Medicare. So be sure to double-check your plans details with your insurance provider.

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Settings For Physical Therapy Care

Does Medicare Cover Rehab?

Medicare also designates which settings patients can be in when receiving Part B services. These include the following:

  • Outpatient hospital therapy offices
  • Skilled nursing facility long term care units
  • Certain homecare situations
  • Physician offices

In all cases, these are considered outpatient visits. In the case of the patients in a SNF long term care unit, typically these are residents of the SNF and have exhausted or are no longer eligible for SNF Part A coverage. Note this does not include inpatients in an acute care hospital, an inpatient rehab facility or an acute rehab hospital who are all covered under Medicare Part A.

One area of coverage that is often confusing are patients under observation status in an acute care hospital. All services for these patients are covered under Part B because the hospital has not admitted them. This makes them outpatients and the hospital has 3 days to decide whether to admit them or send them home.

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Does Medicare Pay For In

Medicare Part B coverage includes outpatient physical therapy services delivered in a clinic or in the patient’s home. This is a great benefit to Medicare beneficiaries who have completed home health physical therapy under Medicare Part A and are now planning to transition to outpatient therapy services.

Mobile physical therapists who are contracted with Medicare part B may bring all of the skill and convenience to your home.

Some of the more common conditions treated by a physical therapist in the patient’s home include post surgical care for individuals who have received a total knee replacement, total hip replacement, and rotator cuff repair.

If you have been referred to outpatient physical therapy services and would like to find a physical therapist in your area that is a contracted Medicare provider and able to deliver covered services.

If you would like to find therapists in your area please use our search feature.

What Are The Medicare Caps For Physical Therapy Coverage

Medicare no longer caps medically necessary physical therapy coverage. For outpatient therapy in 2021, if you exceed $2,110 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.

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Who Can Provide Physical Therapy Services

Medicare designates who can provide physical therapy to its beneficiaries. Provision of these services must fall within their scope of practice as determined by state and local laws.

The following can provide physical therapy and bill Medicare for it:

  • Physicians
  • Non-physician providers like PAs, APRNs, or Clinical Nurse Specialists
  • Physical Therapists and supervised Physical Therapist Assistants and
  • Qualified persons with or without a license, trained and qualified to provide PT care only under the direct supervision and incident to a physician or NPP.

Furthermore, they also clearly note who cannot provide billable Medicare services. PT aides, rehab technicians, athletic trainers, massage therapists, exercise physiologists, recreation therapists, kinesiotherapists, pilates instructors and life skills trainers are not considered qualified to provide physical therapy services to patients with Medicare. CMS is about ensuring that safe care is provided for Medicare beneficiaries. They believe only those trained in physical therapy, such as physical therapists or PTAs, possess the necessary skills to provide effective and appropriate care to this population. If one has not been trained in physical therapy, then they are not qualified to manage Medicare patients.

You could certainly argue that physicians, APRNs or PAs receive no training in physical therapy either. However, these are the current Medicare regulations.

Medicare Coverage Of Physical Therapy

Medicare Advantage Reimbursement for Physical Therapy

Your doctor may prescribe Medicare physical therapy for many different reasons. According to the American Physical Therapy Association, physical therapists help restore normal physical function and help prevent impairments, disabilities, and functional limitations resulting from injuries, diseases, and other conditions.

If you need physical therapy and youre wondering what your Medicare physical therapy costs are, this article will help you understand your coverage.

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Kx Modifier And Exceptions Process

If services exceed the annual threshold amounts, claims must include the KX modifier as confirmation that services are medically necessary as justified by appropriate documentation in the medical record. There is one amount for PT and SLP services combined and a separate amount for OT services. This amount is indexed annually by the Medicare Economic Index .

For 2021 this KX modifier threshold amount is:

  • $2,110 for PT and SLP services combined, and
  • $2,110 for OT services.

The threshold process consists of 2 tiers:

  • When patients reach the outpatient therapy threshold for that year, you must use the KX modifier and document the reasons for the additional services.
  • For services over $3,000, a targeted medical review process kicks in.
  • What Are Medicare Physical Therapy Caps

    In the past, Medicare imposed an annual limit, or cap, on the amount of therapy services you could get in any calendar year. The costs for physical therapy, occupational therapy, and speech language pathology all contributed to your annual therapy cap.

    However, as of 2018, Congress eliminated the therapy caps. There is no longer a specific limit on the amount of physical therapy services you can receive in a calendar year, but your health care provider will have to provide extra information in your medical record when your therapy charges reach a certain amount. These amounts are:

    • $2,010 for physical therapy and speech language pathology services combined
    • $2,010 for occupation therapy services

    Once you hit this amount, your doctor will need to note why the services are reasonable and medically necessary.

    If you continue to get physical therapy or other therapy services beyond this amount, your claim may be reviewed by Medicare once the amount reaches $3,000 for either physical therapy and speech language pathology, or occupational therapy. If Medicare determines that your doctor hasnt provided enough information to justify continued therapy, Medicare may decide not to cover any additional services.

    Recommended Reading: What Is Medicare Plan F

    Therapy Received At A Hospital Outpatient Department

    There are financial advantages and disadvantages to receiving Medicare-covered therapy at a hospital outpatient department instead of in a doctor’s or therapist’s office, or at home. One advantage of going to a hospital outpatient department is that Medicare Part B pays the full Medicare-approved amount for the therapy, except for a patient copayment for each visit. Another advantage is that there is no yearly cap on the amount Medicare will pay for therapy provided at a hospital outpatient department.

    The disadvantage is that a hospital outpatient department may charge you an unlimited amount above the Medicare-approved amount for the therapyan amount you are personally responsible for. Medicare pays hospital outpatient departments differently from how it pays doctors and other providers. Unlike charges for doctors or other providers, for each service, the patient may be responsible for a copayment that varies with the type of service provided. These copayments are sometimes smaller than the 20% coinsurance amount you would pay if you received the same service at a doctor’s office or clinic.

    As with individual doctors, the hospital does not have to accept “assignment” of the Medicare-approved amount as the full charge for a particular service. Before you begin therapy at a hospital outpatient department, find out if the hospital will accept “assignment” of the Medicare-approved amount as the total amount of the bill.

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  • Do Medicare Supplement Insurance Plans Cover Physical Therapy

    Physical Therapy Us Definition

    Medicare Supplement insurance plans are designed to help pay your out-of-pocket costs under Part A and Part B. Plans sold today do not pay any costs associated with Medicare Part D prescription drug plans, and they cant be combined with a Medicare Advantage plan.

    Medicare Supplement insurance plans are sold by private insurance companies. Medicare Supplement basic benefits are standardized and set by the federal government. In most states, there are standardized plans with lettered names, such as Medicare Supplement Plan G. What this means is that Medicare Supplement Plan G sold by one insurance company has essentially the same benefits as Plan G sold by another company. Three states have their own standard plans.

    Medicare physical therapy services are generally covered by Medicare Part B. The cost sharing for most Part B services is 80/20. That is, usually Medicare pays 80% and you pay a 20% coinsurance. Most Medicare Supplement insurance plans cover all of your Part B coinsurance, although some plans generally pay part of your Part B coinsurance.

    Generally speaking, if Medicare covers a service, your Medicare Supplement insurance plan must also cover at least part of it. For most medical services, if Medicare denies the claim, your Medigap plan will also deny it. Most providers automatically bill your Medicare Supplement insurance plan once Medicare pays its share.

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    What If Medicare Won’t Cover All My Physical Therapy

    Medicare no longer caps how much medically necessary physical therapy it will cover throughout the year. But in some cases, doctors might recommend physical therapy beyond what Medicare considers medically necessary. In this case, you may be stuck paying for additional treatment sessions out of your own pocket.

    To help pay these costs, you could turn to Medicaid, which helps some low-income people, pregnant women, and families cover their health care costs.

    Otherwise, consider switching from Original Medicare to Medicare Advantage. Many Medicare Advantage plans cover more services than Original Medicare, so you could find a plan that pays for more physical therapy.

    Learn more about the differences between Original Medicare and Medicare Advantage.

    What Was The Ruling On The Medicare Improvement Standard

    In January 2013, the US District Court for the District of Vermont ordered CMS to clarify sections of its Medicare Benefit Policy Manualwhich, as it turns out, does not require improvement as a condition of coverage. As part of this settlement, CMS also had to create and distribute new educational materials to correct long-standing and widespread misunderstandings about the Improvement Standard. While the settlement went into effect immediately for Medicare and Medicare Advantage plans, CMS had until January 2014 to comply with this order.

    Here are some important things to note:

    You can read the settlement agreement in full here and the two-page fact sheet that CMS compiled here.

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    When Does Medicare Pay For Physical Therapy

    In order for physical therapy to qualify for Medicare coverage, it must be considered medically necessary. That means the treatment must be for one of the following reasons:

    • To improve your current condition
    • To maintain your current condition
    • To slow any further deterioration of your condition

    Your physical therapy must also be performed by a qualified professional such as a physical therapist or doctor.

    There is no annual limit on the physical therapy costs that Medicare may cover. However, once a certain threshold of spending is reached, the physical therapist must confirm that the services remain medically necessary to treat your condition. In 2020, that threshold is $2,080 and is subject to change each year.

    In order to show that the treatment is medically necessary, your physical therapist will document:

    • Your diagnosis
    • Type of physical therapy youll be receiving
    • Long-term goals of the physical therapy
    • Number of physical therapy sessions youll receive in a day or week
    • Total number of physical therapy sessions needed

    If physical therapy claims exceed $3,000 within a calendar year, a targeted medical review may be required.

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    Medicare Fee Schedule for Outpatient PHYSICAL THERAPY Services *** 2019 *** #MedicareBilling

    Those needing physical therapy should look into whether Medicare will cover the cost. If its deemed medically necessary, you can avoid paying high fees completely out of pocket.

    Outpatient therapy includes therapy received at a therapists or doctors office, Comprehensive Outpatient rehabilitation Facilities , skilled nursing facilities and even at-home therapists. If youre looking for more coverage than what Plan B has to offer, there are other Medicare health plans to consider.

    Here is a rundown of what each plan covers:

    • Part A: hospital insurance that covers inpatient hospital stays, care in a nursing facility, hospice care, etc.
    • Part C: a Medicare Advantage plan that provides you with both Part A and Part B coverage
    • Part D: prescription drug coverage
    • Medigap: Supplement insurance sold by private companies that can help pay for remaining costs that your Medicare plan does not cover

    Search online to learn more about Medicare health plans. You can research each plan and decide which one makes most sense for you. And if you ever want to make adjustments to your plan in the future, you can do so during Medicares annual open enrollment period.

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    Elements Of Patient Care

    For Medicare Part B beneficiaries, the therapist must complete and document the following elements of patient care:

    • Evaluation: Before treatment can begin, the therapist must complete an initial evaluation of the patient. This evaluation should include:
    • Medical diagnosis
    • Objective observation
    • Assessment
    • Plan
  • Plan of Care : Based on the assessment, the therapist will develop a plan of care, which includes details of treatment, estimated time frame for treatment, and anticipated results. At minimum, Medicare requires the POC to include:
  • Medical diagnosis
  • Long-term functional goals
  • Type of services or interventions
  • Quantity of services or interventions
  • Frequency of treatment
  • Duration of treatment
  • Please note that if a patient is receiving treatment in multiple disciplines , then there must be a POC for each specialty, and each therapist must independently establish what impairment or dysfunction he or she is treating as well as the associated goals.

    Furthermore, POCs require the dated signature of the referring licensed physician within 30 calendar days.

    • Daily/Treatment Notes: The therapist must update the patient file for every therapy visit. Daily notes include such details as:
    • whether the patient showed up for the session
    • what took place at that appointment
    • how much time was spent performing services and
    • any observations that the therapist made while working with the patient.

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