Please note that I am in no way a Medicare specialist. I have simply read the publicly available documents and done my best to interpret them for you. The information presented here is relevant for Medicare Part B (Medical Insurance) only. Medicare Part A (Hospital Insurance) and Medicare Part C (Medicare Advantage) programs have different guidelines.
Whenever I think or talk about sticky subjects, I like to start with assuming positive intent of all parties involved. Whether or not the other party has positive intent is somewhat irrelevant — assuming they do puts me in a better place.
So, let’s start with some assumed positive intent for each party
- Patient
- To get better/healthier
- Physical Therapist (PT)
- To help the patient to get better/healthier in a way that is consistent with their training and experience
- Centers for Medicare & Medicaid Services (CMS)
- To allow its beneficiaries to receive the care they need by covering some or all of the cost
- To ensure its beneficiaries are receiving high quality, effective care
- To minimize fraud and abuse in the healthcare system
Rehabilitation vs. Maintenance vs. Wellness
Rehabilitation
When most of us think of physical therapy, we think of rehabilitation. Something happens — injury, illness, new diagnosis, etc. — and physical therapy is an intervention to help us heal and get back to normal physical function.
Rehabilitative therapy includes services designed to address recovery or improvement in function and, when possible, restoration to a previous level of health and well-being.
MEDICARE BENEFIT POLICY MANUAL CH. 15 SECTION 220.2 C
Maintenance
Maintenance has become something of a dirty word in the field, and perhaps more broadly in society. We often think things are working only if they’re improving. However, in the case of a progressive disease or chronic condition, maintenance can be a very appropriate approach.
The goals of a maintenance program would be, for example, to maintain functional status or to prevent or slow further deterioration in function.
MEDICARE BENEFIT POLICY MANUAL CH.15 SECTION 220.2 D
Wellness
Rehabilitation and maintenance approaches are focused on returning to or preserving a baseline level of function, respectively. The wellness approach, in contrast, is often focused on improving the baseline. The goal is for you to be better than you were before, not the same.
Wellness services can also involve a physical therapist acting in a manner that is not considered “skilled” by Medicare. This could include personal training services, health coaching, lifestyle counseling, etc.
Wellness services related to physical therapy are not covered by Medicare at this time.
Services that do not meet the requirements for covered therapy services in Medicare manuals are not payable using codes and descriptions as therapy services. For example, services related to activities for the general good and welfare of patients, e.g., general exercises to promote overall fitness and flexibility and activities to provide diversion or general motivation, do not constitute therapy services for Medicare purposes.
MEDICARE BENEFIT POLICY MANUAL CH. 15 SECTION 220.2 A
Medicare Myths
Myth #1: If my physical therapist thinks I need the service, Medicare will cover it
Not so. The physical therapist must demonstrate that the service is reasonable and necessary under Medicare’s (lengthy) guidelines in MEDICARE BENEFIT POLICY MANUAL CH. 15 SECTION 220.2 B.
Let’s look at some additional excerpts:
A service is not considered a skilled therapy service merely because it is furnished by a therapist or by a therapist/therapy assistant under the direct or general supervision, as applicable, of a therapist. If a service can be self-administered or safely and effectively furnished by an unskilled person, without the direct or general supervision, as applicable, of a therapist, the service cannot be regarded as a skilled therapy service even though a therapist actually furnishes the service. Similarly, the unavailability of a competent person to provide a non-skilled service, notwithstanding the importance of the service to the patient, does not make it a skilled service when a therapist furnishes the service.
MEDICARE BENEFIT POLICY MANUAL CH. 15 SECTION 220.2 A
Myth #2: There is a cap or upper limit on the amount of physical therapy Medicare will cover
There used to be. But even then, it could be extended if the therapy was deemed reasonable and necessary. The Bipartisan Budget Act of 2018 repealed the therapy cap, but retained the “Targeted Review Threshold,” which basically draws attention to therapy care that exceeds a certain amount per calendar year. It’s nothing you would need to worry about as a patient, but something that your therapists should be aware of.
As an aside, if ever there were a case for the “Oxford comma,” it’s this one. Because of the lack of an Oxford comma in some legislation, occupational therapy has a $3,000 threshold, but physical therapy and speech language pathology have a combined $3,000 threshold.
Myth #3: Medicare does not cover maintenance therapy
There are scenarios when Medicare will cover maintenance therapy. They generally involve conditions with high complexity, and the therapist’s role is usually to assess, re-assess, educate, and delegate. Typically, Medicare will not cover the therapist actually carrying out the care.
Selected examples from Medicare:
Example #1 reflects a typical outpatient scenario in which a patient has been receiving ongoing therapy under a physical therapy plan of care and the physical therapist begins the establishment of the maintenance program prior to the patient’s anticipated discharge date.
MEDICARE BENEFIT POLICY MANUAL CH.15 SECTION 220.2 D
EXAMPLE: A patient with Parkinson’s disease is nearing the end of a rehabilitative
physical therapy program and requires the services of a therapist during the last week(s) of treatment to determine what type of exercises will contribute the most to maintain function or to prevent or slow further deterioration of the patient’s present functional level following cessation of treatment. In such situations, the establishment of a maintenance program appropriate to the capacity and tolerance of the patient by the qualified therapist, the instruction of the patient or family members in carrying out the program, and such reassessments and/or reevaluations as may be required may constitute covered therapy because of the need for the skills of a qualified therapist.
Example #4 describes another scenario where the skilled services of a therapist are needed to actually carry out the maintenance program services.
MEDICARE BENEFIT POLICY MANUAL CH.15 SECTION 220.2 D
EXAMPLE: A patient with a long history of Multiple Sclerosis has difficulties transferring in and out of the wheelchair and maintaining range of motion (ROM) of the lower extremities (LEs) due to increased spasticity muscle tone since the most recent exacerbation episode of her Multiple Sclerosis. The beneficiary is unable to walk but is independent with the use of her wheelchair. The beneficiary needs to be able to safely transfer in and out of her wheelchair by herself or with the assistance of a family member or other caregiver(s). After an individualized assessment by the physical therapist, and given the patient’s overall medical and physical condition, the skills of the physical therapist are required to instruct the patient and/or caregivers in proper techniques of wheelchair transfers and LE stretches due to the special medical complications from the progression of Multiple Sclerosis. When the physical therapist determines that the patient can carry out the transfers and stretching activities safely and effectively, either alone or with the assistance of the caregivers, the skills of the physical therapist are no longer necessary to furnish the maintenance therapy; and, the patient is discharged from PT.
Myth #4: Medicare covers 100% of the cost of approved services
Typically Medicare covers 80% of physical therapy (and other outpatient services) after your deductible is met, meaning that the remaining 20% is your responsibility. Read here for more information on Medicare costs.
Secondary insurances may cover some or all of the 20% that Medicare does not cover.
I want physical therapy. Now what?
If you have a condition that requires rehabilitative or maintenance therapy…
- Contact your physician
- Medicare requires the involvement of your physician in your physical therapy plan of care
- It is often most efficient to request a referral for physical therapy from your physician before starting physical therapy
- Contact a physical therapist
- Make sure the therapist participates with Medicare Part B
- Choose a therapist that is proficient in your area of need
- Schedule an evaluation
- Get started with physical therapy
If you have have a condition that does NOT require rehabilitative or maintenance therapy OR you want to improve your baseline physical function…
- Do your research to find a physical therapist who is willing to provide this type of service
- Not all therapy clinics are set up for wellness services
- Ask a lot of questions
- Wellness services are far less regulated than covered services, so it is important that you screen your wellness provider prior to signing up with them
- Think through how much you are willing to invest in your health
- Since there is no insurance coverage for wellness services, you will be responsible for the cost
- Think of your health as an investment. You want to make sure that you are investing in the right person/organization to get the outcome that you want.
- Also consider how much time and energy you are willing to invest in your health at this time
- Get started and celebrate the investment you’ve made in your health!
To learn more about physical therapy and wellness with me, please visit the Work with Me page.
