Medicare Coverage
Most people are concerned with the costs of treatment or if they can afford physical therapy. Our most frequently asked question in the office is “will Medicare cover their Physical Therapy treatment”? The answer is yes, Medicare will cover for physical therapy and especially for goals of ambulation and functional independence.
Medicare is the primary payer for geriatric patients and Excellent Physical Therapy is a Certified Medicare Provider and as such, we must follow all Medicare guidelines regarding referrals and treatment. Medicare patients must have a prescription from their doctor to begin physical therapy treatment. The rules have recently changed (2008) and a new prescription is needed only at the end of the prescribed number of treatments or 90 days which ever comes first, unless your doctor puts a time limit on his prescription.
Medicare allows for an annual limit of $1,960 per year for Physical Therapy, which equals approximately 12-16 visits per year for the average patient. Medicare now has an exception process that allows patients to receive additional Physical Therapy if they have functional limits and certain diagnoses, multiple diagnoses or complicating factors affecting their medical status that might slow down their recovery. This is called the Medicare Exception Process for Physical Therapy. Below is s list of the diagnoses and codes that are common to many of our patients and are considered by Medicare to be exceptions to the annual dollar limit.
The following diagnoses qualify for the Medicare Exception Process:
| R2689 Abnormality of Gait M1610 Osteoarthritis of Hip Z96649 Total Hip Replacement S72009A Hip Fracture |
R262 Difficulty Walking M1710 Osteoarthritis of Knee Z96659 Total Knee Replacement M810 Osteoporosis |
Most other diagnoses will be subject to the Medicare annual limit of $1,960 as stated above, unless the patient has multiple conditions. An example of this would be the combination of Heart Disease, Respiratory Diseases, and Peripheral Neuropathy causing debilitation, difficulty walking, a decrease in functional activity level, and loss of independence. As always Excellent Physical Therapy will provide our patients with the best “one to one” care available to meet their goals and improve their quality of life.
