Medicare Coverage for Physical Therapy
Yes, Medicare Part B covers physical therapy for joint pain when medically necessary. PT is a cornerstone of conservative treatment and often required before other treatments like injections.
Quick Facts
| Coverage Aspect | Details |
|---|---|
| Covered? | Yes, under Part B |
| Prior Authorization | Not required (usually) |
| Your Cost | 20% coinsurance after deductible |
| Annual Cap Threshold | $2,330 (2025) |
| Cap Exceptions | Available with documentation |
What Medicare Requires
1. Medical Necessity
Medicare covers PT when:
- You have a condition that can improve with therapy
- Treatment requires skilled services (not just exercise)
- Goals are specific and measurable
- Progress is documented regularly
2. Physician Involvement
- Referral or order from a physician
- Treatment plan established by qualified PT
- Periodic review of progress and goals
3. Qualified Provider
- Licensed physical therapist enrolled in Medicare
- Medicare-enrolled facility (hospital outpatient, clinic, or private practice)
- Can also receive PT in certain skilled nursing facilities
Understanding the Therapy Cap
Medicare has a combined annual threshold for PT and speech-language pathology:
2025 Therapy Cap: $2,330
| What Counts | What Doesn’t |
|---|---|
| Physical therapy | Occupational therapy (separate cap) |
| Speech-language pathology | Hospital outpatient PT |
| Combined services | PT in skilled nursing facility |
If You Exceed the Cap
You can still receive therapy with a medical necessity exception:
- Your therapist documents ongoing medical need
- Claims include KX modifier
- Medicare may request additional documentation
- Coverage continues if need is justified
What You’ll Pay
- Part B Deductible: $240 (2025)
- Coinsurance: 20% of Medicare-approved amount
- Typical session cost: $15-$50 per visit
Example:
- PT session approved at $150
- Medicare pays: $120 (80%)
- You pay: $30 (20%)
Types of PT Covered for Joint Pain
Medicare covers various PT approaches for joint conditions:
Manual Therapy
- Joint mobilization
- Soft tissue massage
- Manual stretching
Therapeutic Exercise
- Strengthening programs
- Range of motion exercises
- Balance and stability training
Modalities
- Ultrasound therapy
- Electrical stimulation
- Heat/cold therapy
Functional Training
- Gait training
- Activity-specific exercises
- Home exercise programs
Maximizing Your PT Benefits
Before Starting PT
- Get a physician referral with clear diagnosis
- Choose Medicare-enrolled provider
- Understand your deductible status
- Know your cap threshold remaining
During Treatment
- Attend all scheduled sessions
- Communicate progress and challenges
- Complete home exercises
- Track your functional improvements
To Ensure Continued Coverage
- Ensure documentation shows progress
- Discuss goals with your therapist
- Request cap exception if needed
Skilled vs. Maintenance Therapy
Medicare only covers skilled therapy—not maintenance:
| Skilled Therapy (Covered) | Maintenance (Not Covered) |
|---|---|
| Requires PT expertise | Could be done by non-professional |
| Working toward improvement | Maintaining current level |
| New exercises/progressions | Same routine repeated |
| Complex techniques | Basic exercises |
Key point: Once you’ve reached maximum improvement, Medicare coverage typically ends. Your therapist should transition you to a home program.
PT as Part of Treatment Plan
Physical therapy is often required or recommended before other treatments:
| Treatment | PT Requirement |
|---|---|
| HA Injections | Usually required first |
| Surgery | Pre-hab and post-op |
| Cortisone | Often combined |
| Bracing | Used alongside |
Having documented PT attempts strengthens coverage for subsequent treatments.