How Many Physical Therapy Appointments Does Medicare Cover?

Medicare serves as the primary health insurance program for millions of Americans aged 65 and older, and for younger individuals with certain disabilities. Physical therapy is a covered service under Medicare, supporting rehabilitation and recovery. Coverage depends on factors like the service setting and medical necessity. This article clarifies these elements to help beneficiaries understand their physical therapy benefits.

Medicare Parts and Physical Therapy Coverage

Physical therapy coverage varies across Medicare parts, depending on the care setting.

Medicare Part B, or Medical Insurance, covers outpatient physical therapy services. This includes therapy in a physician’s office, outpatient clinic, rehabilitation center, or a beneficiary’s home. Part B covers services received without an inpatient hospital stay.

Medicare Part A, or Hospital Insurance, covers physical therapy during a qualifying inpatient hospital stay or within a skilled nursing facility (SNF). This coverage is part of broader services for recovery after an illness or injury requiring hospitalization. Physical therapy services are integrated into the facility stay, not billed separately.

Medicare Advantage Plans (Part C) are offered by private insurers. These plans must provide at least the same coverage as Original Medicare (Parts A and B). While Medicare Advantage plans cover physical therapy, they may have different rules regarding costs, provider networks, and administrative processes.

Outpatient Physical Therapy Coverage Requirements

Medicare Part B coverage for outpatient physical therapy depends on medical necessity and specific guidelines. Services must be medically necessary, meaning a qualified healthcare professional certifies the therapy is needed to restore, improve, or prevent a patient’s condition from worsening.

A written plan of care is required for Medicare coverage. This plan, established by the therapist, must detail the patient’s condition, therapy goals, and specific interventions. A physician must certify this plan of care.

While there is no longer a hard dollar cap, Medicare uses a “therapy threshold” for targeted medical review. For 2025, services for physical therapy and speech-language pathology combined exceeding $2,410 trigger this threshold. A separate $2,410 threshold applies to occupational therapy. When expenses surpass these amounts, providers must append a KX modifier to the claim, indicating medical necessity.

The KX modifier signals that the provider attests to continued medical necessity and that supporting documentation is in the patient’s medical record. Claims exceeding a higher threshold of $3,000 for physical therapy and speech-language pathology (and separately for occupational therapy) may be subject to targeted medical review. This review helps ensure extended services remain medically necessary and documented.

Therapists must also report functional limitation information on claims. This helps Medicare assess therapy effectiveness and patient progress, contributing to the ongoing evaluation of medical necessity. Proper documentation is essential for all services, especially those approaching or exceeding financial thresholds, to justify continued coverage.

Inpatient Physical Therapy Coverage

Physical therapy is covered under Medicare Part A when a beneficiary is admitted as an inpatient to a hospital. This therapy is part of the overall hospital benefit, provided the hospital stay is medically necessary and meets Medicare’s inpatient criteria. Physical therapy costs are typically bundled into the hospital’s daily rate, not billed separately.

Physical therapy is also covered as part of a qualifying skilled nursing facility (SNF) stay. To qualify for SNF coverage, a beneficiary must have had a medically necessary inpatient hospital stay of at least three consecutive days before SNF admission. Medicare Part A covers the full cost for the first 20 days of a qualifying SNF stay within a benefit period.

For days 21 through 100 of a SNF stay, beneficiaries are responsible for a daily coinsurance payment of $209.50 in 2025. After day 100, Medicare coverage for the SNF stay ceases, and the beneficiary becomes responsible for all costs unless other insurance applies.

Understanding Financial Responsibilities

Medicare beneficiaries typically incur out-of-pocket costs for physical therapy services. For outpatient physical therapy covered under Medicare Part B, beneficiaries must first meet an annual deductible. In 2025, the Medicare Part B deductible is $257. After meeting this deductible, Medicare generally pays 80% of the Medicare-approved amount. The beneficiary is responsible for the remaining 20% coinsurance. There is no annual limit on this 20% coinsurance under Original Medicare.

Providers must issue an Advanced Beneficiary Notice of Noncoverage (ABN) if they believe Medicare may not cover a service. This occurs if the service is not medically necessary, or if the therapy threshold has been exceeded and continued medical necessity is questioned. By signing an ABN, the beneficiary acknowledges potential non-coverage and agrees to financial responsibility if Medicare denies the claim.

Medicare Advantage Plans may have different cost-sharing structures, such as copayments or deductibles, compared to Original Medicare. These plans typically include an annual out-of-pocket maximum, which limits the total amount a beneficiary spends on covered services in a year. Once this maximum is reached, the plan pays 100% of the cost for covered services for the remainder of the year.

Navigating the Process

Beneficiaries seeking physical therapy under Medicare should locate a Medicare-approved provider. Medicare’s official website offers a tool to search for qualified physical therapists and facilities. Ensuring the provider accepts Medicare is important to facilitate coverage.

A doctor’s order or referral is generally required for Medicare coverage. While some states allow direct access for an initial evaluation, Medicare typically requires a physician to certify the plan of care for ongoing treatment. This ensures therapy aligns with a physician’s medical assessment.

Physical therapy providers usually submit claims directly to Medicare. After processing, beneficiaries receive a Medicare Summary Notice (MSN) or an Explanation of Benefits (EOB) from their Medicare Advantage plan. Reviewing these documents helps track services, billed amounts, and Medicare’s payments.

If Medicare denies coverage, beneficiaries have the right to appeal the decision. The appeal process involves several steps, starting with a redetermination by Medicare.