Medicare covers therapy services to help you regain or maintain your ability to function. Its program covers Americans aged 65 and older who have worked and paid into the system as well as younger people with disabilities. Medicare should pay for therapy whether you need it on a temporary basis to restore your condition, or you need it on an ongoing basis to prevent you from getting worse. After the annual Medicare Part B deductible is paid, Medicare will pay up to 80% of the Medicare-approved amount for each service (generally 18-19 visits) and you will be responsible for the remainder 20% (supplemental insurance suggested ). After the limit has been reached, you will have to pay the full cost of the services (100%).
If you are approaching the limit and need more therapy, your doctor can tell Medicare that it’s medically necessary for you to continue .If you need a lot of care after you have reached the therapy cap, your provider may need to get pre approval from Medicare (KX Modifier) for your care to continue. If Medicare denies the claim, you can appeal through the regular Original Medicare appeals process.
Medicare has four parts:
- Part A is hospital insurance (inpatient)
- Part B is Outpatient therapy center (physical therapy clinic)
- Part C is a private health plan (often called a Medicare Advantage Plan) that Medicare has approved.
- Part D is a prescription drug plan.
Medicare covers outpatient physical, occupational, and speech therapy. Coverage does not depend on a patient’s “potential for improvement from the therapy but rather on the beneficiary’s need for skilled care. Medicare reimburses therapists when the documentation and claim forms accurately report the provision of medically necessary covered services. Furthermore, documentation must comply with all applicable Medicare regulations, defend the services a therapist bills (CPT codes). The therapist must complete and document the following elements of patient care: Evaluation, Plan of Care (POC), Daily/Treatment Notes, and Progress Reports (every 30 days), Discharge Notes, and Certification (physician/NPP approval of the plan).