How long will coverage for Medicare physical therapy last after a knee replacement?

4 answers | Last updated: Nov 23, 2016
Jacklyn asked...

I am covered by Medicare Part B. I have recently had a total knee replacement. How long will coverage for Medicare physical therapy last after a knee replacement?

Expert Answers

Not long. First of all, your physician needs to prescribe the therapy, and periodically needs to review your continuing need for it. But no matter how much therapy your doctor prescribes, Medicare will only pay a limited amount. Once you have paid your yearly Part B deductible, Medicare Part B pays 80 percent of the amount it approves for the therapy; you have to pay the remaining 20 percent out of your pocket, unless you have other insurance such as a Medigap policy. And there is a cap on the total amount Medicare will pay per year for physical therapy; in 2008 it is $1,810. After Medicare has paid that much, it will pay no more regardless of whether your physical therapy is medically necessary and prescribed by your doctor. After the first of the year, a new total amount will be available to you (slightly higher than the 2008 figure).

One way around this limit may be to get some additional therapy from an occupational therapist rather than a physical therapist. Although the name occupational therapy suggests that it is connected to work, in fact occupational therapy helps people who have had serious injuries, surgeries or illnesses to learn safe ways of doing everyday tasks – like walking, getting in and out of bed, lifting things, etc. It is offered by specially trained therapists and is considered by Medicare to be different from physical therapy, and has its own separate $1,810 yearly limit. If your doctor agrees that occupational therapy would be useful for you, the doctor can give you a separate prescription for it and Medicare can cover it in addition to your physical therapy.

To learn more about the rules of Medicare coverage for physical and occupational therapy, look at the Medicare publication Medicare Limits on Therapy Services.

Community Answers

Debsalsa answered...

The response regarding receiving more therapy if you use occupational therapy is WRONG!

If the physical therapist feels that you no longer require skilled physical therapy services, odds are that you are already functioning beyond the scope of what is considered "necessary" for skilled occupational therapy services. OT is concerned with items such as ADL's like bathing, grooming; dressing, etc. If you don't have the necessary strength and ROM to perform these tasks, you probably would not be discharged from physical therapy. This seems like advice to help you skirt around" the definitions of the skill regarding for payment of therapy services. By the way, I am a physical therapist with more than 28 years of experience so I KNOW what I am talking about.

Medicare rules help answered...

Patient reach the desire goal or there is no more improvement from Physical Therapy but physician continue to send patient with prescription that continue PT. What is Physical Therapist's role and next step?

A fellow caregiver answered...

Joseph Matthews above is 100% incorrect. The so-called Medicare cap for Physical Therapy services at $1870 (2012 figure) is a "soft" cap to which a Physical Therapist can go over as medically necessary. If Mr. Matthews actually read the document he linked to, he would find on page 2 the following exception:

"You may qualify to get an exception to the therapy cap limits so that Medicare willcontinue to pay its share for your therapy services. Your therapist must documentyour need for medically-necessary services in your medical record, and your therapist'sbilling office must indicate on your claim for services above the therapy cap that youroutpatient therapy services are medically necessary."

This occurs if the Physical Therapist deems that the patient is indeed progressing towards his/her functional goals and is in need of more therapy services in order to achieve them. The Physical Therapy clinic will attach what is known as a "KX modifier" which allows this exception as needed. Once the amount of $3700 is reached, which is known as the "hard" cap, again more Physical Therapy services can be allowed as medically necessary. However, the Physical Therapist will have to do some extra paperwork in order to justify this necessity to CMS, or will have an audit automatically ordered by CMS that will examine the medical necessity of more therapy.

It would be very important for Mr. Matthews to correct his original post above, based on the information from the link he actually provided.