Physical Therapy Guidelines under Medicare in 2019

Guest post by Danielle K. Roberts of Boomer Benefits

Physical therapy is an important part of treatment plans for many different injuries and illnesses. It can be especially important for those with Parkinson’s as research shows it improves balance and reduces fall risk, improves their ability to walk faster and further, and that it generally improves the quality of their life.

Fortunately, Medicare provides physical therapy (PT), speech-language pathology therapy (SLP) and occupational therapy (OT) for people aged 65 and over here in America as well as some younger people with disabilities.


What is the Medicare “Cap”?

For many years there has been a cap on Medicare’s coverage of physical therapy services, which fall under Medicare Part B. These limits were put in place to control Medicare spending as therapy can be expensive. Congress must also consider the impact of sustained treatment when it comes to maintaining the solvency of Medicare’s Trust Fund for future generations.

Further complicating the issue has been Medicare’s rule of thumb for providing treatment, which in the past has always required that the patient shows medical improvement in order for Medicare to continue providing that treatment. While this seems reasonable on a surface level, it was quite a burden for beneficiaries who are challenged with chronic conditions such as Parkinson’s Disease (PD) or Multiple Sclerosis. It was a burden for their therapists as well.

Therapy is often required for patients with Parkinson’s to simply manage their condition and maintain their current level of health and mobility. The nature of their health condition is that they may never show improvement, but a regimen of physical therapy could keep at them at least at the status quo or significantly delay their decline in mobility.

Medicare’s requirement that improvement must always be shown overlooked the fact that physical therapy was still helping in delaying progression of mobility for several major health conditions.

A change was needed, and it came in the form of recent budget legislation.


Hard Caps Vs Soft Caps

The Bipartisan Budget of 2018 repealed the per-beneficiary Medicare Part B therapy caps which previously have limited some chronically ill patients to only a few months of physical therapy care each year.

The hard caps were initially established in 1997 at $1,500 per year. If therapy was needed beyond this limit, therapists had to initiate an exceptions process to prior authorize any additional therapy to be provided in that calendar year. Congress was continually having to review and renew the caps as well as provide direction on exceptions.

With this change in 2018, lawmakers are now recognizing that sometimes long-term therapy is medically necessary to maintain a certain standard of physical health. They are also relieving immense pressure on therapists to achieve outcomes when a hard cap at $2,010 per patient per year was in place.

Therapy must still be medically necessary. It must be therapy that will mitigate a patient’s risk of incurring a worse outcome if their health condition is left untreated. However, therapists are no longer required to provide proof of medical improvement.

So, beginning in 2019, there is no longer a limit on how much physical therapy you can receive in a given calendar year. However, your therapist may have to provide additional information about medical necessity if your therapy goes beyond a certain soft cap each year.

There is a combined soft cap of $2,010/per year for physical therapy and speech-language pathology and a separate soft cap of $2,010 for occupational therapy. There is also a permanent exceptions process that will allow therapy providers to continue to provide treatment over the soft cap amounts as long as they meet certain requirements.

If billing for PT, SPT or OT goes beyond $3,000 for the year, continued treatment is subject to post-payment medical review. It will be up to the Centers for Medicare and Medicaid services to decide on the triggers that would initiate such a review. However, if the review uncovers that your doctor hasn’t documented enough information to justify continued physical therapy, Medicare could decide not to cover any more therapy that year.

At this point patients could still consider paying cash for additional physical therapy and therapists should be sure to give the patient an Advance Beneficiary Notice of Noncoverage (ABN).


What This Means for People with Parkinson’s Disease

This legislation is a milestone in access to proper care for people with Parkinson’s Disease, as well as people with many other chronic illnesses. People with PD can sometimes struggle to handle the basic tasks of everyday living. PD is a progressive disease, so therapy is an important part of maintaining mobility and independence.

Whereas before patients might not be able to afford therapy care after the hard cap was reached, they will now have Medicare’s financial assistance with the costs of care for a longer period of time. This will certainly have a huge impact on their ability to live independently and stay in their own homes.

Accessing Physical Therapy Under Medicare

To access Medicare-covered care, beneficiaries must get their treatment at a therapist or doctor’s office or at a skilled nursing facility or other comprehensive outpatient rehab facility.

Patients may also receive care through a therapist that is connected with his or her home health agency.

The physical therapy must be ordered by a Medicare physician and performed by a qualified physical therapist. Medicare has an online provider compare tool to help you find therapists in your area who accept Medicare.

Therapists must first prove that your condition warranted their skilled intervention (meaning someone who is non-skilled like a caregiver or spouse could not effectively perform the same services) and is medically necessary (meaning the treatment administered is necessary to improve the patient’s quality of life). Proper documentation of skilled need is dependent on a complete assessment of the patient and their history by the physical therapist..

Your physical therapist should document specific outcome measures that demonstrate your progress in therapy. Therapists can measure many things, including your gait, your balance and risk for falls, your posture, your fitness and endurance, dexterity, muscle strength or weakness, cognitive skills, breathing function and overall quality of life.

However, not all of these items are most effective for demonstrating progress for a person with Parkinson’s. For this reason, it’s important to see a physical therapist who is familiar with Parkinson’s, such as a PWR!MovesⓇ Certified Therapist or an LSVT BIG Certified Therapist.

While there are certainly a number of rules still in play surrounding physical therapy for patients with chronic illnesses, these recent changes are a step in the right direction.


Danielle K Roberts is a Medicare insurance expert and co-founder of Boomer Benefits, where she and her team help Medicare beneficiaries navigate their benefits and select suitable supplemental coverage.