Injury · Recovery

PT and OT: the Medicare therapy "limit" is just paperwork

The cast comes off. The surgeon says "you'll need therapy." Then the clinic mentions a dollar "threshold," and you start counting visits. Physical or occupational? Both? What happens when the money runs out? Here's the secret: for medically necessary therapy, Original Medicare's money doesn't run out. Once you see how it's built, you can stop rationing the care that gets you home.

Photo: Yan Krukau / Pexels

PT moves your body. OT runs your day.

The two sound alike and get mixed up all the time. They work side by side, but each has its own job.

Physical therapy (PT) is about movement: strength, balance, range of motion, walking, stairs. The physical therapist sets a plan and uses hands-on care and exercise to get you moving and ease pain.

Occupational therapy (OT) is about daily life: getting dressed, bathing, the bathroom, cooking. The occupational therapist changes the task, the tool or the home so you can do it, and can suggest equipment that makes the day safer.

• Leg, ankle or hip? Walking and stairs come first, so PT usually leads.
• Hand, wrist or arm? Buttons, jars, writing and washing your hair are OT territory. Some people see OT first.
• A bigger injury, especially in an older adult? Many people need both: PT to walk safely, OT to manage the shower and the kitchen.

And if an injury leaves something behind, like a wrist that never fully turns or a hip that needs a cane for good, that's exactly what OT is built for. The goal shifts from "back to how it was" to "living well with how it is."

The $2,480 number that isn't a cap

Medicare Part B helps pay for medically necessary outpatient PT and OT. Your doctor, nurse practitioner or physician assistant has to certify that you need it. After the Part B deductible, you pay 20% of the Medicare-approved amount.

And there is no yearly limit on what Medicare pays for medically necessary outpatient therapy.

So what's the "threshold"? For 2026 it's $2,480 for physical and speech therapy combined, and a separate $2,480 for OT. Above that, the clinic adds a code to each claim (the "KX modifier") confirming the therapy is still medically necessary and written up in your records. That's it. If your notes support it, care can continue.

Other plans, home visits and work

Medicare Advantage must cover what Original Medicare covers, so PT and OT are in. The difference is the rules: you may need approval first (prior authorization), a referral, or an in-network therapist.

Employer and Marketplace plans vary a lot. Many set a number of visits per year. Every U.S. state lets you see a physical therapist without a doctor's referral, but some plans still want one. Ask before the first appointment, not after the fifth.

Can't leave home without a lot of effort or help? Medicare home health can bring PT and OT to the house, and for covered services you pay nothing. Our guide walks through it: Medicare home health, the benefit most families never use.

If you work, talk to HR early. Ask about short-term disability and the Family and Medical Leave Act (FMLA). FMLA gives eligible employees up to 12 weeks of unpaid, job-protected leave, and it can be taken in pieces for therapy appointments.

Questions to ask:

• The doctor: "When can therapy start, and should it be PT, OT or both?"
• The plan: "How many PT and OT visits do I have this year, and do I need a referral or prior authorization?"
• The therapist: "What should I be able to do in four weeks?"
• Yourself, before you stop: "Am I done, or am I just out of pain?"

If you're here after a broken bone

Each of our guides to common breaks covers the first weeks and what recovery looks like:

• Broken wrist: what happens next
• Broken ankle or sprain?
• Hip fracture: what families should know
• Broken collarbone
• Broken arm

The 60-second recap

• PT rebuilds movement. OT rebuilds your day. Many people need both, so ask for OT by name.
• Original Medicare Part B: you pay 20% after the deductible, with no yearly limit.
• The 2026 $2,480 threshold is paperwork (the KX code), not a cap.
• Medicare Advantage and other plans: ask about visit limits, referrals and prior authorization first.
• Homebound? Medicare home health brings therapy to the door. Working? Ask HR about FMLA.

Education, not medical, legal or insurance advice.

Sources

• Medicare.gov — Physical therapy services
• Medicare.gov — Occupational therapy services
• CMS — Therapy services (KX modifier threshold, CY 2026)
• Medicare.gov — Compare Original Medicare and Medicare Advantage
• Medicare.gov — Home health services
• ChoosePT (APTA) — About physical therapists and physical therapist assistants
• ChoosePT (APTA) — Physician referral not needed
• MedlinePlus — Rehabilitation
• U.S. Department of Labor — Family and Medical Leave Act