For those of you who have government-issued Medicare, let's review the requirements Medicare has to ensure, for them to cover your expenses, that you're getting treatment that has been deemed medically necessary and requires skilled intervention. Like any and all insurance, you should be aware there are going to be different monetary limits depending upon the type of treatment you seek.


To determine medical necessity for physical therapy, you'll be asked to complete an Objective Outcome Measurement, or a survey that helps, both, you and your therapist place a numerical value on your progress as your treatment continues. You'll complete one at the beginning of treatment, and will continue to complete these 10-12 question scaled surveys every 30 days, or 10 visits - whichever comes first, with your final survey completed upon discharge. 


To determine medical necessity for physical therapy based upon your therapist's professional opinion, Medicare has inset a number of functional tests that cover a wide variety of conditions, disorders, and procedural protocols. These functional tests are a mix between subjective and objective, as the tests are judged/ranked on a numerical scale similar to that of the Objective Outcome Measurement, but require a licensed practitioner to be correctly evaluated.

Tests such as these that are popular for an outpatient, orthopedic rehabilitation clinic such as CHAMPION Performance & Physical Therapy include functionality tests such as: a 5-time Sit-to-Stand test which measures how quickly, yet safely, a patient can stand up and sit down 5 times. Based on the results, the patient is ranked on his/her functionality. 


With physical therapy, you'll meet two separate caps - caps being financial limits. The first of the two is around $1,900. This is equivalent to around 10-15 visits, depending upon the clinic patients attend. This cap does not necessarily mean Medicare is going to cut you off, but it does, in fact, mean that your therapy will be monitored for medical necessity more closely - and you, in turn, will be required to complete more paperwork. 

The second cap of the two is around a total of $3,700. Again, depending upon the clinic, this will be equivalent to 20-30 visits. This cap is a hard limit, and if treatment has still been deemed medically necessarily, a secondary insurance will have to be utilized. 

The Medicare caps both encompass all diagnoses throughout the year.

Make sure to contact Medicare for the specifics of your plan, including your annual renewal date (typically Jan. 1), as well as your coverage for physical therapy. Plan accordingly with your physical therapist if you know you'll require more visits later in the year for a different diagnoses to get the most out of each session, and talk to your doctor to ensure your procedure and/or prescription to physical therapy allows you to utilize your visits efficiently. 

For our patients, if you have any further questions about your account or plans, please feel free to contact us at (913) 291 - 2290