General Health

Understanding Medicare Physical Therapy and Its Guidelines

By Nicole R March 08 March 15th, 2021 No Comments

By Kelly K Veit

When You Need More Physical Therapy But Don’t Know Where To Turn

Millions of elderly Americans rely on Medicare as their insurance provider to cover their medical needs. How, when, and for how long Medicare covers physical therapy treatment can be very confusing. The guidelines can also have unforeseen consequences to those relying on its policies for their care.

Medicare provides medical coverage under multiple parts, but for physical therapy these services are covered under Medicare Part A and Medicare Part B.

  • Medicare Part A coverage applies to physical therapy provided as an inpatient, such as in the hospital or a rehabilitation facility, but also when the patient is homebound. Homecare physical therapy is offered in this situation.
  • Medicare Part B covers those services received in a nursing home or in an outpatient clinic.

Regardless of location, Medicare will only pay for physical therapy treatments if it is considered medically necessary. Medically necessary can be a confusing phrase within the scope of Medicare.

  • The necessity for treatment is established by the physical therapist at the first evaluation. The patient’s treatment diagnosis and health challenges associated with it, such as weakness, pain or balance deficits, must be deemed appropriate for physical therapy care.
  • There must also be achievable goals that the patient can meet within a reasonable timeline.

According to the Center for Medicare & Medicaid Services (CMS), a treatment plan needs to be created and “the plan should strive to provide treatment in the most efficient and effective manner.” [1] Medicare also has loose guidelines regarding the use of physical therapy following extended bed rest or generalized weakness. This may not be covered by Medicare physical therapy as there is no reasonable or necessary need for it. It is assumed that a person would gradually recover on their own in such a situation. [1]

For many aging adults, an injury can lead to a perpetual cycle of accessing Medicare benefits for physical therapy without ever realizing “return-to-normal-life” expectations. What may begin as a hospital stay for an injury, can include a transfer to a rehabilitation facility to further strengthen, and finally a return home. Again, Medicare will only cover physical therapy as long as the client is meeting goals that can be measured within a designated time frame. In reality, the client may be sent home having met initial stated goals or bumped up against the designated time frame to achieve those initial goals, but still be in a weakened state because… policy has deemed that physical therapy will not be covered by Medicare beyond that point, even if sufficient strength has not been regained.

Most often, individuals soon decline upon returning to their home, as they do not exercise as consistently as they did while in the rehab facility. There may be extenuating circumstances that prevent the individual from exercising on their own, i.e., lack of “how-to” exercise knowledge, fear of falling, depression, lack of motivation. Without a dedicated therapist focusing on the needs that best serve the individual and the encouragement to continue with daily movement and activity, they may decline so severely that they lose the ability to walk or balance. This can then lead to another injury and the cycle starts over. Unfortunately, between the time frame of returning home and the next potential injury, there is no insurance coverage for continued physical strength building.

There is Hope

The team of Physical Therapists at Tandem Strength & Balance specializes in physical therapy in-home services to break this devastating cycle. Our individualized, strengthening and balance programs are geared to addressing the aging seniors’ unique needs to get and stay strong and move independently, confidently and safely. We are not limited by Medicare guidelines and continue to focus on what is needed to keep our clients living their best life. Contact us today for a free in-home consultation.

We help people to understand why they are struggling
and what steps can be taken to make life better.


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