Medicare.gov says there's no limit on how much Medicare pays for your medically necessary outpatient therapy services in a calendar year. After the Part B deductible ($283 in 2026), you pay 20% of the Medicare-approved amount. Once your therapy costs pass a yearly threshold, $2,480 in 2026 for physical therapy and speech-language pathology combined and a separate $2,480 for occupational therapy, your therapist must add a "KX modifier" to claims to confirm the care is still medically necessary.
Is there a cap on Medicare physical therapy?
Not anymore. The Centers for Medicare & Medicaid Services (CMS) explains that the Bipartisan Budget Act of 2018 kept the old therapy cap amounts as thresholds instead of hard limits. Medicare.gov's physical therapy page says there's no limit on what Medicare pays for medically necessary outpatient therapy in one calendar year.
What is the KX modifier?
A modifier is a short code added to a claim. CMS says that once your therapy costs for the year go above the threshold, claims must include the KX modifier. It confirms that the services are medically necessary, as supported by your medical record. CMS says claims over the threshold without the KX modifier are denied.
For 2026, CMS lists the KX modifier thresholds as:
- $2,480 for physical therapy and speech-language pathology services combined.
- $2,480 for occupational therapy services.
These amounts count the total Medicare-approved cost of your therapy, including the part Medicare pays. They're adjusted each year.
What do I pay for physical therapy?
Medicare.gov says that after the Part B deductible, you pay 20% of the Medicare-approved amount when the services are medically necessary. Medigap may pay some or all of your 20%. Medicare Advantage plans set their own copays and may require prior authorization or limit visits before approval.
Can therapy be covered just to maintain my condition?
Yes. Medicare.gov says you can get therapy to help improve or maintain your current function, or to slow your rate of decline. You don't have to be getting better for therapy to be covered, as long as it's medically necessary and needs a therapist's skills.
Why did I get a bill for physical therapy?
- Your 20% coinsurance after the deductible.
- The Part B deductible if it's early in the year.
- A denied claim that was over the threshold and missing the KX modifier. Ask the office to correct and resubmit it.
- Services Medicare decided weren't medically necessary. If the therapist expected this, they should have given you an Advance Beneficiary Notice of Noncoverage (ABN) before the service.
- Medicare Advantage rules, like a missing prior authorization.
What is an ABN, and does it apply to therapy?
An Advance Beneficiary Notice of Noncoverage (form CMS-R-131) is a notice a provider gives you before a service if they believe Medicare may not pay. It lets you decide whether to get the service and pay if Medicare doesn't. CMS says the ABN is used to transfer potential financial liability to you in certain cases. If you were billed for a denied service and never got an ABN, ask the provider why you're being billed, and check the instructions on your MSN.
How do I check a therapy bill?
- Match each visit to your Medicare Summary Notice. Check dates and the number of units billed. Some therapy services are billed in timed units. If the number of units looks off, ask the office how they were counted.
- Track your yearly total. Your therapist's office can tell you how close you are to the threshold.
- Look for denials. If a claim was denied for a missing KX modifier, ask the office to fix and rebill it.
- Ask about any ABN if you're billed for a non-covered service.
- Confirm Medigap paid its share.
What should I say to the therapy office?
"My Medicare Summary Notice shows a denied therapy claim for [date]. Was it over the yearly threshold? If so, can you add the KX modifier and resubmit it with your notes? Also, did I sign an ABN for this service?"
What if my therapist says Medicare won't cover more visits?
Ask why. If they say there's a cap, you can point out that Medicare.gov says there's no limit on medically necessary outpatient therapy. If the therapist believes more therapy isn't medically necessary, ask your doctor for their opinion. If Medicare denies a claim, you can appeal using the instructions on your MSN.
Frequently asked questions
Does Medicare limit physical therapy visits?
Medicare.gov says there's no limit on what Medicare pays for medically necessary outpatient therapy in a calendar year.
What is the 2026 KX modifier threshold?
CMS lists $2,480 for physical therapy and speech-language pathology combined, and $2,480 for occupational therapy.
What do I pay for outpatient physical therapy?
20% of the Medicare-approved amount after the Part B deductible.
Does Medicare cover therapy to maintain my condition?
Yes. Medicare.gov says therapy can be covered to improve or maintain your current function, or slow your decline.
Want help keeping track of therapy bills?
Bill Review Coach is a monthly medical bill review service for seniors and their families. Snap photos of your therapy bills and Medicare notices, and we'll check the visits, units, and denials, and tell you what to ask the office. You make the calls and write the emails; we help you know what to say.
General information, not legal advice. Check your own bill and notices.