How Many Physical Therapy Sessions Will Medicare Pay For?

Medicare provides coverage for a wide array of medical services, including physical therapy, which aids in recovery from injuries, managing chronic conditions, and improving functional abilities. Understanding Medicare’s coverage rules for physical therapy is important for patients.

Medicare Coverage for Physical Therapy

Medicare covers physical therapy services primarily through Original Medicare (Parts A and B) or Medicare Advantage Plans (Part C). Medicare Part A covers inpatient physical therapy during a hospital stay or in a skilled nursing facility (SNF) after a qualifying hospital stay. Part A may cover physical therapy for up to 100 days in a SNF, with full payment for the first 20 days and a daily copayment for days 21-100.

Medicare Part B covers outpatient physical therapy services. These services can be provided in a doctor’s office, an outpatient rehabilitation facility, a hospital outpatient department, or at home under specific conditions. For both Part A and Part B, coverage requires the service to be “medically necessary.” A service is medically necessary if it is needed to diagnose or treat an illness, injury, condition, or its symptoms, and meets accepted standards of medicine. This includes therapy aimed at improving, maintaining, or slowing the deterioration of a patient’s functional abilities.

Medicare Advantage Plans (Part C) are offered by private companies and must cover at least the same benefits as Original Medicare Parts A and B. These plans may have different rules regarding costs, provider networks, and prior authorization requirements. Beneficiaries with a Medicare Advantage Plan should review their specific plan documents.

Establishing Medical Necessity and Therapy Plans

To ensure Medicare covers physical therapy services, establishing medical necessity through proper documentation and a structured plan of care is necessary. A physician’s order or referral is required. Services must be skilled and performed by qualified healthcare professionals, such as licensed physical therapists.

A written “plan of care” is a required document for outpatient rehabilitation therapy services. This plan must include the patient’s diagnoses, long-term treatment goals, and the type, amount, duration, and frequency of the therapy services. A physician or non-physician practitioner (NPP) must certify this plan of care within 30 days of the initial therapy treatment.

Recertification of the plan of care is necessary every 90 days or whenever there is a significant change in the patient’s condition. For claims on or after January 1, 2025, a new exception allows a signed and dated order or referral to meet initial certification requirements, provided the order is in the patient’s medical record and the plan of care was submitted to the referring provider within 30 days of the initial evaluation.

Medicare’s Therapy Thresholds and Review Process

Medicare Part B does not impose a hard “cap” on the number of physical therapy sessions. Instead, it uses annual financial thresholds that trigger closer review of services. For 2025, the threshold for combined physical therapy and speech-language pathology services is $2,410. A separate threshold of $2,410 applies to occupational therapy services.

When a patient’s therapy costs reach these thresholds, the provider must attach a “KX modifier” to claims. The KX modifier allows for an “automatic exception,” meaning services can continue without immediate denial, provided medical necessity is justified.

Beyond the initial threshold, a “targeted medical review” process may occur if total therapy expenses exceed $3,000 for a benefit period. This $3,000 threshold is expected to remain in place until at least 2028. Not all claims exceeding this amount are automatically reviewed; Medicare focuses on providers with high denial rates, unusual billing patterns, or those who are newly enrolled. If a claim is selected for targeted medical review, providers may need to submit additional documentation to justify medical necessity.

Receiving and Billing for Physical Therapy

Once medical necessity is established and a plan of care is in place, patients can receive physical therapy services. For Original Medicare Part B, beneficiaries are responsible for certain out-of-pocket costs. After meeting the annual Part B deductible, which is $257 for 2025, Medicare covers 80% of the Medicare-approved amount for physical therapy services. The patient is responsible for the remaining 20% coinsurance.

Physical therapy providers submit claims directly to Medicare. Beneficiaries with Original Medicare receive a Medicare Summary Notice (MSN), which details the services received, the amount Medicare approved, and the patient’s responsibility. For Medicare Advantage Plans, an Explanation of Benefits (EOB) serves a similar purpose, outlining how the plan processed the claim.

Patients should review these notices to understand charges and payments and identify discrepancies. Medicare Advantage plans may have varying copayments or coinsurance amounts for physical therapy, and some may require services from within a specific network to avoid higher out-of-pocket costs.