Medicare covers physical therapy (PT) services that are medically necessary, but the exact cost per visit is not a single, fixed number. Determining the cost depends entirely on the specific Medicare plan—Original Medicare (Part A or Part B) or a Medicare Advantage (Part C) plan—and the setting where the therapy is provided. Outpatient therapy is handled differently than therapy received during a facility stay, which significantly influences a patient’s out-of-pocket costs.
Outpatient Coverage Under Medicare Part B
Outpatient physical therapy, the most common setting for beneficiaries, is covered under Medicare Part B, provided the services are medically necessary. This coverage applies to PT received in a therapist’s office, an outpatient clinic, or a hospital outpatient department. Financial responsibility is calculated based on a fixed percentage of the amount Medicare approves for the service, not the total amount billed by the provider.
Before Medicare pays its share, the beneficiary must first meet the annual Part B deductible. Once satisfied, Medicare pays 80% of the approved amount for each subsequent physical therapy visit. The beneficiary is responsible for the remaining 20% coinsurance for every visit, which is the primary out-of-pocket cost under Original Medicare.
The actual dollar amount of the 20% coinsurance fluctuates based on the specific services rendered and the provider’s geographic location. A visit involving a complex therapeutic procedure results in a higher approved amount and, consequently, a higher 20% coinsurance payment from the patient.
Understanding the Annual Therapy Threshold
The amount of therapy a patient receives in a year is monitored through an annual dollar threshold to ensure that services remain medically appropriate even with high utilization. For 2025, the combined total cost for outpatient physical therapy and speech-language pathology (SLP) services must be tracked against a threshold of $2,410.
When a beneficiary’s total costs reach this $2,410 threshold, the therapist must confirm the services are medically necessary by adding a “KX modifier” to the claim submitted to Medicare. Attaching this modifier attests that the documentation supports the need for continued therapy, allowing Medicare to continue paying its 80% share without interruption. This threshold requires the provider to formally affirm the medical necessity of the ongoing treatment.
A second, higher threshold is set at $3,000 for 2025 to trigger a targeted medical review (MR) of claims. If a provider’s claims exceed this dollar amount, they may be subject to a review process. This review is not automatic for all claims surpassing $3,000 but typically targets providers with unusual billing patterns or high denial rates to maintain program integrity.
Physical Therapy Coverage in Facility Settings
Physical therapy provided in an inpatient setting, such as a Skilled Nursing Facility (SNF) or an Inpatient Rehabilitation Facility (IRF), is covered under Medicare Part A. This model bundles therapy into the daily rate for the facility stay, meaning there is no per-visit cost for the physical therapy itself. Part A coverage is based on benefit periods, and the patient’s cost-sharing is a daily rate that covers all services, including the room, meals, skilled nursing care, and therapy.
For an SNF stay, a beneficiary pays $0 for the first 20 days of care, provided they meet the qualifying criteria. Beginning on day 21 and continuing through day 100 of the benefit period, the beneficiary is responsible for a daily coinsurance amount, which is $209.50 for 2025.
Since physical therapy is included in the total daily cost, the patient does not receive a separate bill or pay a separate coinsurance for each session. After day 100 in a benefit period, Medicare Part A coverage ceases, and the beneficiary becomes responsible for all costs of the SNF stay. This bundled payment structure contrasts sharply with the per-visit cost-sharing model of Part B.
Medicare Advantage Plans and Costs
Medicare Advantage Plans (Part C) are an alternative to Original Medicare and must cover at least the same services, including physical therapy. However, the cost structure for beneficiaries is often completely different from the 20% coinsurance model of Part B. These plans, offered by private insurance companies, typically replace the percentage-based coinsurance with fixed copayments for PT visits.
A patient might pay a set amount, such as $20 or $30, for each physical therapy session, rather than 20% of the approved charge. The exact copayment amount is highly variable and depends entirely on the specific plan chosen by the beneficiary. Before enrolling, it is necessary to check the plan’s Evidence of Coverage (EOC) document for the precise cost-sharing details.
These plans often utilize network restrictions, such as Health Maintenance Organization (HMO) or Preferred Provider Organization (PPO) models, which also influence out-of-pocket costs. Seeing a physical therapist outside the plan’s network usually results in significantly higher costs or no coverage at all. Unlike Original Medicare, Medicare Advantage plans also include an annual out-of-pocket maximum, which limits the total amount a beneficiary must pay for covered services in a year.