…… What are medicare’s limits on physical therapy for knees?

[Barry Natchitoches]

What are the limits for getting physical therapy for your knees, if you have Medicare?

I know that there are yearly limits, but I am wondering what they are, as my knees are in really bad shape.


Also, if I would have knee replacement surgery, would the amount of physical therapy that they cover be higher?

one other question — I understand that physical therapy for the knees BEFORE knee replacement surgery is a good thing, as the stronger the muscles are going into the surgery, the better the recovery after the fact.

But if I were to go into a regimen of PT before surgery, would they cut the amount of PT they will pay for after surgery?

Thank you in advance for your insights and shared knowledge.

 

[WalknTrot]

What are the limits for getting physical therapy for your knees, if you have Medicare?

I know that there are yearly limits, but I am wondering what they are, as my knees are in really bad shape.


Also, if I would have knee replacement surgery, would the amount of physical therapy that they cover be higher?

one other question — I understand that physical therapy for the knees BEFORE knee replacement surgery is a good thing, as the stronger the muscles are going into the surgery, the better the recovery after the fact.

But if I were to go into a regimen of PT before surgery, would they cut the amount of PT they will pay for after surgery?

Thank you in advance for your insights and shared knowledge.

Get the pre-surgical exercises from your surgeon. You can do them yourself...that's what I did. Frankly, I didn't do formal PT after the knee replacement either...just did my prescribed exercises (again- from the surgeon) religiously at home. Turned out great.

As far as Medicare coverage of PT goes...not sure, but I think Part B covers 80%. I did do 6-8 weeks of PT for each of my shoulder joint replacements (WHOLE different deal than the knee because you can't use the joint/start PT for 6 weeks - you really need a whip-cracker and have to be monitored much more carefully) and they cost me out-of-pocket $30/session. (Some of this will probably depend on your particular supplemental coverage).

 

[ioujc]

Have your pre-surgery exercises at the end of this year. Have surgery in early January of 2024, and have the post-surgery rehab exercises following surgery!!

There's no limit on how much Medicare pays for your medically necessary outpatient therapy services in one calendar year.

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Author: Lindsay Malzone|

Physical therapy services - Your Medicare Coverage​

After you meet your Part B deductible, Medicare will cover 80 percent of medically necessary physical therapy costs, with no limit on outpatient physical therapy coverage.

Medicare can cover physical therapy at home, in skilled nursing facilities, and in outpatient rehabilitation facilities.

 

[Ogre]

Barry,
Sorry, I cannot answer your question and I don't mrean to thread drift, but it sounds like you have no additional insurance. Maybe you have already checked, but if not I suggest you check into an Advantage plan.

It may not be available in your area, but we have a Humana Gold Advantage plan that costs us zero $, we simply assign our medicare benefits to them. (We still haave the monthy medicare premium deducted from mour SS checks.)

Maximum out of pocket $3500/year this year. 15+ years ago wife needed countless PT and OT sessions. Since she had already reached the then max out of pocket of $3500 (total bills oer $350,000) there was no additional cost.

Others must have similar plans. Hope something works out for you.

 

[colonel holman]

I am a Medicare-certified Dr of Physical Therapy.
Outpatient PT care does NOT a limit (used to, but no longer). Instead, you are qualified to receive PT as long as the PT care is SKILLED enough to warrant a PT and is provided by a PT or Licensed PT Assistant under the direct on-site supervision of a PT… and there is reasonable expectation there will be SIGNIFICANT IMPROVEMENT in a reasonable time frame (evidenced by measurable gains in ROM, Strength, and Function).

Regarding Medicare Advantage plans… our clinic and many others REFUSE to accept patients insured by most (not all) of these plans, as most have their own rationing rules (some limiting PT care to only 6 visits per year). In our state Medicaid limits PT to only 2 sessions per year. Many Advantage plans take a year to pay their bills for PT. There are a feew plans that are very good (I use one myself) but generally most are a ripoff. The HEAVY advertising is very expensive, implying they are doing very well with their profits. The huge list of covered services (even grocery shopping for you) are generally lies. Most inpatient rehab facilities refuse to accept these patients as they cannot get bills paid.

Good versus bad Advantage plans vary from state to state… but here we refuse those plans by Cigna, Humana, Harvard Pilgrim

Medicare covers 80% of the Medicare Fee Schedule.

If you have Home Health right after surgery, you are not allowed to start outpatient PT until HH is totally finished. Post op PT usually runs 2 or 3 sessions per week for 6-9 weeks. Outcomes are generally excellent, with most stating they wush they had done this earlier.

 

[Barry Natchitoches]

Barry,
Sorry, I cannot answer your question and I don't mrean to thread drift, but it sounds like you have no additional insurance. Maybe you have already checked, but if not I suggest you check into an Advantage plan.

It may not be available in your area, but we have a Humana Gold Advantage plan that costs us zero $, we simply assign our medicare benefits to them. (We still haave the monthy medicare premium deducted from mour SS checks.)

Maximum out of pocket $3500/year this year. 15+ years ago wife needed countless PT and OT sessions. Since she had already reached the then max out of pocket of $3500 (total bills oer $350,000) there was no additional cost.

Others must have similar plans. Hope something works out for you.

Oh, heavens — there is NO WAY I would EVER fall for a Medicare so-called Advantage plan, and neither should anybody else.

Oschner’s so-called Advantage plan refused to treat my father, leading to his death.

And my wife would be dead by now, IF she had one of those plans - as they generally provide as little cancer care as they can get away with, when you have metastatic cancer as she has.

Not long ago, thete was an entire thread here on the hidden dangers of those so-called Advantage plans.

They might offer a few sexy extras to healthy people, but when you need them the most, they cut off your care to save money.

Even when the care they refuse to authorize is life saving care.

I am asking about regular medicare.

 

[Barry Natchitoches]

I am a Medicare-certified Dr of Physical Therapy.
Outpatient PT care does NOT a limit (used to, but no longer). Instead, you are qualified to receive PT as long as the PT care is SKILLED enough to warrant a PT and is provided by a PT or Licensed PT Assistant under the direct on-site supervision of a PT… and there is reasonable expectation there will be SIGNIFICANT IMPROVEMENT in a reasonable time frame (evidenced by measurable gains in ROM, Strength, and Function).

Regarding Medicare Advantage plans… our clinic and many others REFUSE to accept patients insured by most (not all) of these plans, as most have their own rationing rules (some limiting PT care to only 6 visits per year). In our state Medicaid limits PT to only 2 sessions per year. Many Advantage plans take a year to pay their bills for PT. There are a feew plans that are very good (I use one myself) but generally most are a ripoff. The HEAVY advertising is very expensive, implying they are doing very well with their profits. The huge list of covered services (even grocery shopping for you) are generally lies. Most inpatient rehab facilities refuse to accept these patients as they cannot get bills paid.

Good versus bad Advantage plans vary from state to state… but here we refuse those plans by Cigna, Humana, Harvard Pilgrim

Medicare covers 80% of the Medicare Fee Schedule.

If you have Home Health right after surgery, you are not allowed to start outpatient PT until HH is totally finished. Post op PT usually runs 2 or 3 sessions per week for 6-9 weeks. Outcomes are generally excellent, with most stating they wush they had done this earlier.

Do they send you home the same day after one total knee replacement?

or do they keep you over night, and start PT while you are still in the hospital?

This is important to me, as - for reasons I do not care to discuss on a public forum - I will be having my surgery in Nashville, and I live four hours away outside of Memphis.

BTW, I have the Medigap Part G plan, as well as regulat Medicare Parts A, B and D.

 

[colonel holman]

Usually not an overnight, but there can always be a complication with coming out of anesthesia, excess bleeding, problems encountered by surgeon, etc. But these are rare.

Also try to get PT to show you your home exercises before you go to surgery, as learning these immediately after surgery are not well-retained. Also have them show you the proper technique for using crutches on stairs before surgery so you will already know this after surgery. Harder to learn this right after surgery

Some folks are chickenshit about pain, not a mental defect, just the way they are wired. They are too afraid to do much for rehab home exercises. They can get poor outcomes. Another group are those who are hellbent to force progress and push themselves too hard too soon, creating too much inflammation and persistent swelling that risks failed recovery

 

[Barry Natchitoches]

What I am afraid of is being driven four hours in a car immediately after leaving the hospital.

Nashville is an extremely expensive place to get a hotel room in.

And then, not being able to get to PT therapy at all the next day or two.

I actually live somewhere outside Memphis, in a rural area. In an area that has no nearby PT facility at at all, so I would face a four hour car trip home, and then, no option for home PT services. It would be a minimum 30 minute drive each way to get to a PT provider that locals trust.

 

[colonel holman]

Then make sure you are wearing those tight anti-embolism stockings that reduce swelling and (especially) prevent blood clots in calf. Keeping leg elevated as best as car ride will allow. Stop every half hour for you to get our and walk about very short walk to activate muscles and joint movement. Prolonged sustained sitting is not good, so interrupt it frequently during the ride. Missing starting PT for two days is no big deal.

 

[Macgyver]

My mom just had a knee replacement.
Surgery was done in the morning but they still kept her overnight.
She was to walk and use it almost immediately. I think she said unless she was sleeping she was supposed to walk around every half hour.
She started pt within a few days.
She is using a pt place from a totally different hospital group. 5 min drive vrs 45-50


I have no idea about the Medicare coverage questions.

 

[rafter]

I had a total knee just a little over 2 years ago. I had my surgery later in the day so I got to stay in the hospital overnight. I actually then chose to stay an extra day since I live alone.

Please try to get your doctor to send you home with a 'ice machine'. My doctor does it automatically. It circulates ice water through a wrap around wrap.....it is a Godsend and I spent most of my recovery for the first week or 2 with it on most of the time. It really helped so I didn't have to take the pain pills.

Also I have advantage insurance and it paid great. Most of my expense was the extra night in the hospital and PT. I paid $700 out of pocket.

 

[bluelady]

Medicare required dh to have physical therapy before they would approve knee replacement. He was bone on bone & doctor said it was pointless, but there you are.

(He ended up not having the surgery after all, but that part wasn't Medicare's fault.)

 

[rafter]

I didn't have to do any Pt prior to surgery. I did have several injections prior to replacement....and I had no problem with that because I was willing to try anything that would help.

I need the other one done now and the injections do nothing for it, so I am just trying to get through till late fall when work slows down and horse show season is over.

 

[WalknTrot]

Far as I know, nobody has to do the pre-surg exercises, but they speed up recovery greatly. Maybe some surgeons have their own protocol/requirements. There is where you really need to nail everything down. The other thing you can nail down is the financial aspect with your surgeon's dept. and the hospital billing dept.

Barry - what the Col. said is straight from the horse's mouth. Also, from what I've seen during and post-covid, they are sending folks home asap after these things - same day in most cases. Back 8 years ago when I had my knee done, it was two overnights in the hospital and PT in the hospital 2x/day. Now, it's same day and out. Depends on the surgeon and how the patient reacts post-surg. Talk to him or his office/head nurse.

 

[Griz3752]

At my age and given my history, the OP got my immediate attention.

Thanks for that and all the follow on comments; good information.

 

[Doug997]

I had a TKR three weeks ago. Being in the best shape you can is certainty helpful (I biked 15 miles the day before my procedure). My procedure was in the morning and I went home by 6pm however I should have stayed over for pain management (I had a nerve block and spinal). I passed the tests for release and it was my choice to go home although the Dr wanted me to stay which is his normal process. Some may say it is old school but they sent me a knee continuous passive motion (CPM) machine which I found very useful. I am also doing PT but I was told you really only need one or the other. My goal was to do a full rotation on my bike by the end of the first month which I did yesterday. I will now mostly focus on the bike moving forward and expect to be back hiking in two months (3 months from procedure).

 

[WalknTrot]

I had a TKR three weeks ago. Being in the best shape you can is certainty helpful (I biked 15 miles the day before my procedure). My procedure was in the morning and I went home by 6pm however I should have stayed over for pain management (I had a nerve block and spinal). I passed the tests for release and it was my choice to go home although the Dr wanted me to stay which is his normal process. Some may say it is old school but they sent me a knee continuous passive motion (CPM) machine which I found very useful. I am also doing PT but I was told you really only need one or the other. My goal was to do a full rotation on my bike by the end of the first month which I did yesterday. I will now mostly focus on the bike moving forward and expect to be back hiking in two months (3 months from procedure).

I did the exercises diligently before the surg. and had stressful, immediate responsibilities and timeline to get back to functional. (Both parents in health crisis - cancer and dementia - and I was their sole caregiver). I get where Barry is coming from. Because of the preparation (plus a darned ridiculously/scary high tolerance for pain), I was stumping around feeding and doing barn chores with the walker and driving my 5 speed (clutch) truck the day I came home. (Left knee replaced).

But very thankful, even with this last shoulder that I was able to stay the night in the hospital - the surgeon took me in late in the day, being tied up with a couple of emergency surgeries. As it turns out, I have a history of my BP completely tanking the morning after surgery. Haha...this time, even though I'd warned them and it was in my previous charts, I scared the wee out of my nurse, who had the sense and autonomy to dump in a bag of fluids while frantically trying to get hold of my surgeon who was 100 miles away that morning doing his rural community outreach. Anyway...there might be good reasons even these days why it might be wise to stay the night.

Oh yeah...and ain't nerve blocks awesome?

 

[dioptase]

My experience.... I had regular (PPO) insurance last year - they fought tooth and nail to not pre-certify knee replacement (they didn't like my weight). We appealed and they were forced to approve it, but then the surgeon suggested to me (for a variety of reasons) that we wait anyway (and try to lose X lbs meanwhile.... I lost more than that). In the meantime, the insurance company announced that they were not renewing my policy. (It's unclear if it was because they were discontinuing that policy for everyone, or they just wanted to drop ME. We didn't care... it was $$$$, DH was already on an HMO Medicare Advantage Plan tied to our (very good) medical service, and he wasn't having any issues with it.)

So now I'm on that same Medicare Advantage Plan, and they approved the knee replacement instantly at the start of the year. No push back, no refusing to pre-certify it, no problems.

I asked the surgeon about PT pre-op, and he said to save my $. There will be PT post surgery.

I am supposed to be in the hospital at least overnight. The surgeon says that it all depends... They won't let me out until the physical therapists at the hospital are convinced that I can take care of myself (bathroom, dressing, manage stairs, so on), and of course if there is an infection they won't let me go either. PT will supposedly be done out of my home (news to me!); that hasn't been arranged yet.

 

[anna43]

I don't know the answer to your question, but I do know that if PT says you are not making progress or have achieved your goals therapy will have to end. Guess that is one of few Medicare rules that make sense.

 

[dioptase]

Barry, if you are getting knee replacement surgery, how are you going to be able to take care of your wife? I just finished an online pre-op class, and they say that YOU will need a "coach" (someone to look after you, encourage you, make you do your exercises, etc.) for at least 5-7 days post-op. (Based on meniscal tear surgery I had on one knee, I'd think it would be longer, more like 10 days, but my surgeon claims that the recovery will be quicker. Hard to believe.)

Keep in mind, too, that you are going to be using a walker for some amount of time (my surgeon said 6-8 weeks), and then a cane for some number of weeks after that. You won't be able to drive for something like 6-8 weeks, depending on which knee is being operated on.

I really hope you have someone that you can get to help both you and your wife during your recovery period.

 

[ohiohippie]

At my 6 week post TKR appt. my Dr. said I can go to PT until my therapist and I agree I no longer need it.
At 8 weeks out I no longer need PT specifically for my knee.
We are working on my gait, balance and core strength.
I go to PT 3 times weekly.
PT told me as long as I show need I can continue. There is a man there that’s been going almost 2 years.

Medicare pays 80%. My secondary insurance pays the rest minus a 10$ co-pay.

Good Luck!

PT is giving my quality of life back.

 

[rafter]

It will all depend on the person as to how fast you are rehabbing.

Before surgery I asked my surgeon how long before I could ride horses again and he said 4 weeks. I worked towards that with PT even though they were shocked when I told them the week I was going to start again.

4 weeks to the day I was back in the saddle for a half hour the first time then progressed from that.

You have to get up and do it.

Another thing is how it is done. My doctor uses the robo which is all precise in cuts and fit which greatly improves how fast you come back. There are still doctors out there using a saw and hammer. Ask how they do it.

 

[ohiohippie]

What I am afraid of is being driven four hours in a car immediately after leaving the hospital.

Nashville is an extremely expensive place to get a hotel room in.

And then, not being able to get to PT therapy at all the next day or two.

I actually live somewhere outside Memphis, in a rural area. In an area that has no nearby PT facility at at all, so I would face a four hour car trip home, and then, no option for home PT services. It would be a minimum 30 minute drive each way to get to a PT provider that locals trust.

You should be eligible for Home Health PT.
I had a 3 hour drive home after surgery. I was fine. My daughter helped me out and back in car for a short spin with the walker half way home.
My knee was still numb from surgery and a pain cocktail before helped with the ride. I didn’t feel any pain.
Be Well!