Medicare does not set a limit on how many physical therapy sessions it will cover. Instead of capping visits, Medicare uses an annual dollar threshold to flag claims for extra review once your charges get high enough. For 2026, that threshold is $2,480 in combined physical therapy and speech-language pathology charges under Part B. As long as the therapy is medically necessary and your therapist documents it properly, coverage continues past that figure with no fixed ceiling on the number of sessions.1Centers for Medicare & Medicaid Services. Therapy Services
The $2,480 Threshold Is a Checkpoint, Not a Cap
Before 2018, Medicare did impose hard dollar caps on outpatient therapy, and coverage stopped once you hit them. The Bipartisan Budget Act of 2018 permanently eliminated those caps and replaced them with a softer threshold. Reaching the threshold no longer ends your coverage.
Once your Part B physical therapy and speech-language pathology charges combined reach $2,480 for the year, your therapist has to add a KX modifier to each claim. That modifier is the therapist’s attestation that continued treatment is medically necessary and that the clinical record supports it. Claims submitted above the threshold without the KX modifier are denied automatically.1Centers for Medicare & Medicaid Services. Therapy Services Occupational therapy has its own separate $2,480 threshold.
A second checkpoint sits at $3,000. Claims above that level may be flagged for targeted medical review, in which a contractor examines the documentation to verify medical necessity. This review process runs through 2028 under the same law that created the threshold system.2APTA. Medicare Payment Thresholds for Outpatient Therapy Services Getting flagged is not the same as being denied. When the record shows why the therapy is still needed, claims above both thresholds routinely get paid.
What Has to Be True for Sessions to Keep Counting
Medicare’s willingness to keep paying rests on three things being in place. A physician or qualified provider must certify that the therapy is medically necessary. There must be a written plan of care that spells out the treatment, frequency, and duration. And that plan has to be recertified at least every 90 days by a physician, nurse practitioner, clinical nurse specialist, or physician assistant, who confirms you still need continued therapy.3eCFR. 42 CFR Part 424 Subpart B – Certification and Plan Requirements
If a recertification window slips past without a review, it can open a gap in coverage. Track when your plan was last signed off. This is the same paperwork that supports the KX modifier once you cross the threshold, so keeping it current matters more the longer you stay in therapy.4Centers for Medicare & Medicaid Services (CMS). Outpatient Rehabilitation Therapy Services: Complying with Documentation Requirements
You Don’t Have to Be Improving
A common misconception is that Medicare stops paying for physical therapy once you stop making measurable progress. That has not been the rule since the Jimmo v. Sebelius settlement in 2013. Medicare covers skilled therapy to maintain your current condition or slow a decline, not only therapy aimed at restoring lost function.5Centers for Medicare & Medicaid Services. Frequently Asked Questions (FAQs) Regarding Jimmo Settlement Agreement
The word that carries weight here is “skilled.” Medicare pays for maintenance therapy when the exercises or interventions are complex enough that a trained therapist has to perform or supervise them. If you could safely do the program on your own or with help from a family member, Medicare won’t cover a therapist to oversee it. If your condition requires clinical judgment to manage safely, coverage continues even without measurable improvement. Many claims that get denied in this category are denied because the documentation doesn’t explain why a skilled professional is required, not because the therapy itself is inappropriate. Ask your therapist to document the skilled nature of the care at every visit.
What You Pay Per Session
Under Original Medicare, you first pay the Part B annual deductible, which is $283 for 2026.6Medicare.gov. 2026 Medicare Costs After that, you pay 20% of the Medicare-approved amount for each session, and Medicare pays the remaining 80%. On a session with an approved amount of $150, your share is $30.
One detail worth knowing: when a physical therapist assistant provides your treatment rather than the physical therapist, Medicare reduces its payment by 15%, and the claim must carry a CQ modifier. Your 20% coinsurance percentage doesn’t change, but the practice receives less from Medicare for those visits, which can affect how clinics staff your care.
A Medigap policy may cover some or all of the 20% coinsurance. Medicare Advantage plans handle cost sharing differently, often charging a flat copay per visit instead of percentage coinsurance.
Medicare Advantage Can Set Visit Limits
Everything above about thresholds, the KX modifier, and percentage coinsurance applies to Original Medicare. If you’re enrolled in a Medicare Advantage plan, the plan must cover at least as much physical therapy as Original Medicare, but it can structure the benefit differently.7Medicare.gov. Medicare Coverage of Therapy Services Many Advantage plans impose visit limits, require prior authorization, or restrict you to in-network therapists.
The $2,480 threshold and KX modifier process don’t apply to Medicare Advantage claims. Your plan uses its own utilization management rules instead. If the plan denies additional visits, the appeal runs through the plan first, not directly through Medicare. Read the Evidence of Coverage or call the plan before starting therapy so you know what needs approval and how many visits are on the table.
Session Limits That Do Apply in Other Settings
The no-cap rule covers outpatient therapy under Part B. Two other settings have their own rules.
Inpatient physical therapy during a hospital stay falls under Part A and is bundled into your hospital coverage, so the outpatient threshold doesn’t apply. Physical therapy in a skilled nursing facility after a qualifying hospital stay is also Part A. Qualifying requires at least three consecutive days as a hospital inpatient (observation hours don’t count) and entry into the facility within 30 days of discharge. Medicare then covers up to 100 days per benefit period, with days 1 through 20 fully covered and days 21 through 100 requiring a daily coinsurance payment. After day 100, you pay the full cost.8Medicare.gov. Medicare Coverage of Skilled Nursing Facility Care
Home health physical therapy is a separate benefit for people who are homebound. It doesn’t require a prior hospital stay, and there’s no coinsurance under Original Medicare, though a physician must certify that you’re homebound and need skilled therapy.9Centers for Medicare & Medicaid Services (CMS). Home Health Services
If a Session Gets Denied
When your therapist expects Medicare to deny a specific service, they’re required to give you an Advance Beneficiary Notice of Noncoverage before providing it. The ABN lists the service, an estimated cost, and the reason they think Medicare won’t pay. You can accept the service and financial responsibility while preserving your right to appeal, pay outright without a claim, or decline the service and owe nothing.10Centers For Medicare & Medicaid Services (CMS). Advance Beneficiary Notice of Non-coverage Tutorial If a provider skips the ABN and Medicare denies the claim, they generally can’t bill you.
If Medicare denies a claim, you have 120 days from the denial notice to request a redetermination, the first level of a five-level appeals process.11Centers for Medicare & Medicaid Services. First Level of Appeal: Redetermination by a Medicare Contractor Send the medical records, therapist’s notes, and certified plan of care with the appeal. Denials most often turn on documentation gaps, so an appeal that ties the therapy to a specific functional limitation and explains why a skilled therapist is required has a real chance of overturning the decision.12Medicare. Appeals in Original Medicare