Timed units, plan-of-care certification, KX and assistant modifiers, and payer visit limits handled for PT, OT and SLP practices, with front-desk help, patient marketing and a claims portal.
Quick answer
Physical therapy billing services turn each visit into a correct claim: timed units counted from total minutes, GP, GO or GN modifiers, KX and assistant modifiers when they apply, and a certified plan of care behind every claim. Occupational and speech therapy follow similar rules. RCM Finder adds front-desk assistants, marketing and a claims portal.
Therapy billing is different because payment depends on minutes, plans and thresholds, not only on the visit. A claim can be coded correctly and still be denied because the plan of care was never certified or the units do not match the documented minutes.
Medicare’s rules are a useful baseline. CMS’s MLN905365 fact sheet (May 2022) says every outpatient therapy claim needs a GP, GO or GN modifier and documentation of total timed minutes for each date. Commercial and Medicare Advantage plans add visit limits and prior authorization.
If your practice mainly bills surgery or injections, our orthopedic billing and pain management billing pages fit better.
The CMS Therapy Services page (modified March 2026) lists the CY 2026 KX threshold at $2,480 for PT and speech-language pathology combined and $2,480 for OT. It also says telehealth authority for PT, OT and SLP runs through December 31, 2027. Since 2025, CMS allows general supervision of assistants by therapists in private practice.
Therapy is paid under the fee schedule. The CY 2026 final rule set the non-qualifying conversion factor at $33.40. The CY 2027 proposal (July 14, 2026) projects $32.84. Check the final rule before you budget.
A therapy practice needs patients and referrers who find you, a front desk that tracks visits and signatures, billing that counts minutes correctly, and software that shows each claim. Revenue leaks at the handoffs, so we run all four on one set of payer rules.
Our healthcare digital marketing reaches patients searching for care, referring physicians, surgeons and employers, through local SEO, Google Ads and reputation work, with tracking kept off forms that collect health information.
Our virtual medical assistants for therapy practices work on your practice’s time zone. They check benefits and visit limits, request authorizations, book evaluations and track the signature dates that Medicare needs.
Our end-to-end rehabilitation revenue cycle management covers coding support, claim scrubbing, denial management and A/R follow-up, with extra checks for units, discipline modifiers, KX, CQ and CO, and NCCI pairs.
Our practice management system tracks every claim by stage, applies specialty-aware billing logic per claim, checks data completeness before submission and flags underpayments.
Find where your therapy claims leak
We review recent claims, denials and authorization logs, then show what to fix first.
Each therapy rule has a deadline, a threshold or a pairing limit. Codes are described in our own words (the AMA owns CPT descriptors); check the current code set and your Medicare contractor. For basics, see our physical therapy CPT codes guide and evaluation and treatment codes post.
| Topic | Code or modifier examples (our wording) | Rule to know | Typical denial trigger |
|---|---|---|---|
| Timed treatment | 97110 (exercise); 97140 (manual therapy); 97530 (activities) | Units follow total timed minutes: 8 to 22 is 1 unit, 23 to 37 is 2 | Units above documented minutes; no total timed minutes |
| Untimed and group | 97150 (group); supervised modalities 97010 to 97028 | Untimed codes bill 1 unit; supervised modalities may share a 15-minute period | Group billed as individual; two timed services in the same 15 minutes |
| Evaluations and re-evaluations | PT 97161 to 97164; OT 97165 to 97168 | One evaluation or re-evaluation per date per practitioner; routine re-evaluations are not billable | Re-evaluation billed to update the plan |
| Discipline modifier | GP (PT); GO (OT); GN (speech) | Required on listed therapy codes | Missing or mismatched modifier |
| Medicare KX threshold | KX | CY 2026: $2,480 for PT and SLP combined; $2,480 for OT. KX attests necessity | KX added by habit, or missing above the threshold |
| Assistant services | CQ (PT assistant); CO (OT assistant) | Assistant furnishes over 10% of a service’s minutes; paid at 85% | CQ without GP; CO without GO |
| Plan of care | Certifier’s NPI on the claim | Certify within 30 days; recertify every 90 days; progress report every 10 treatment days | Unsigned or late plan; no certifier on the claim |
| NCCI pairs | Modifiers 59, XU, XS | Only with documented separate intervals or sites; indicator 0 edits cannot be bypassed | 59 added with no documentation |
Sources: Medicare Claims Processing Manual ch. 5 (§§10.7, 20.1, 20.2); CMS Therapy Services page (2026); CMS MLN905365 (2022); CMS CQ/CO billing examples (2026); CGS LCD L34049 fact sheet (2025–2026); Medicare NCCI Policy Manual ch. 1 and 11 (2026); AAPC code pages (plain-language meanings only). Rules vary by contractor and payer.
The Medicare Claims Processing Manual, chapter 5 says an untimed code is billed as one unit. Timed codes follow a table: 8 to 22 total timed minutes is one unit, 23 to 37 is two, 38 to 52 is three. Minutes are summed across timed services for the day; three 7-minute services (21 minutes) support one unit. Time per intervention need not be in the note, but total timed minutes must be. Our billing units guide gives the general idea; use this table for Medicare and check each commercial payer’s method.
The same chapter reduces the practice expense part of payment for multiple procedures: full work and malpractice payment, but 50% of practice expense for later units and services on the same day.
The manual requires GP, GO or GN on listed therapy codes, with CQ paired to GP and CO to GO. KX attests that services are reasonable, necessary and documented; the CMS Therapy Services page also sets a separate $3,000 targeted medical review threshold.
The CMS CQ/CO billing examples (February 2026) explain the test: full units an assistant furnished get CQ or CO, then the remainder does when the assistant’s share is above 10%. If the therapist gave 8 or more minutes of the final unit, it is billed without the modifier.
CMS’s MLN905365 lists the plan elements: diagnoses, long-term goals, service type, treatment, and its amount, frequency and duration. A physician or nonphysician practitioner certifies it with a dated signature within 30 days of the first treatment day, or signs a verbal order within 14 days. Recertify at least every 90 days; write a progress report at least every 10 treatment days. Noridian adds that recertification needs no visit and is not billable, while a re-evaluation is payable for a significant change.
CGS, the contractor for Kentucky and Ohio, summarizes LCD L34049: from January 1, 2025, a referral-based initial certification can be met by a signed, dated order plus one-time transmission of the plan to the referring provider within 30 days. Missing certification is a technical denial. Other contractors may differ.
The NCCI Policy Manual, chapter 1 (2026) calls modifier 59 a last resort and says X modifiers such as XU and XS should replace it where possible. A modifier cannot bypass an edit with indicator 0, and the record must support whichever modifier you use. In chapter 11, some PT and OT pairs can be bypassed with 59 or XU when the services occur in different timed intervals, and a routine re-evaluation is not reported. Our modifier 25 vs 59 guide covers the general rule.
Chapter 11 bars one speech-language pathologist from billing 92507 or 92508 on the same date as 97129, 97130 or 97533, and says SLPs do not bill 97110, 97112, 97150 or 97530. One practitioner reports one PT or OT evaluation per date. CMS defers to state licensure for who may furnish speech services. Under the Jimmo settlement, Medicare also covers skilled maintenance therapy, so “no progress” alone is not a valid denial.
Most states let patients see a physical therapist without a referral, but Medicare still needs a physician or nonphysician practitioner to certify the plan of care, and some plans have their own referral rules.
The American Physical Therapy Association’s September 2023 state summary says 48 states allow evaluation and treatment without a referral, unrestricted or with provisions; Alabama and Mississippi are limited. Provisions include visit or day limits, such as Georgia (21 days or 8 visits) and California (45 days or 12 visits). Georgia and New York require notice that a plan may not cover care without a referral. The summary does not address Medicare.
State law changes, so confirm yours. A patient may walk in, but Medicare still needs a certifier, and a commercial plan may ask for a referral anyway. Our VMAs record both before the first visit.
Check coverage before the evaluation, then again when visits run low. Rules differ by plan, state and benefit year.
For Medicare Advantage, CMS’s 2024 final rule fact sheet (April 2023) says plans must follow Medicare coverage criteria for basic benefits and keep approvals valid as long as treatment is reasonable and necessary. Coordinated care plans must give a 90-day transition to members switching plans mid-treatment. Since January 1, 2026, the CMS-0057-F rule requires Medicare Advantage, Medicaid and CHIP plans to decide urgent requests in 72 hours and standard ones in seven calendar days, with a specific reason for any denial.
Plans still set their own process. UnitedHealthcare’s January 2025 notice says its Medicare Advantage authorization for physical, occupational and speech therapy covers the entire plan of care. The first 6 visits within 8 weeks skip clinical review for members new to the office, with a new condition or a gap of 90 or more days, and evaluations need no authorization. Other payers differ.
For commercial plans, the essential health benefits rule (45 CFR 156.115) says plans must not set habilitative limits less favorable than rehabilitative limits, and must not combine the two. Ask each plan how it counts visits, evaluations and each discipline. For the general approval workflow, read our prior authorization guide for providers.
| Check | Why it matters (source) | What the VMA records |
|---|---|---|
| Plan type | Medicare Advantage plans may require prior authorization (UnitedHealthcare example) | Plan type and its rule |
| Visit limit and visits used | Plans may cap visits; the federal essential health benefits rule bars combined habilitative and rehabilitative limits | Limit, visits used, benefit year start |
| Authorization | UnitedHealthcare’s MA notice covers the whole plan of care; first 6 visits in 8 weeks skip clinical review | Request date, approved visits, expiry, due date |
| Referral or direct access | State rules vary; some require notice that a plan may not pay without a referral (APTA, 2023) | State; referral or notice on file |
| Medicare certifier | A physician or nonphysician practitioner certifies; the NPI goes on the claim (Manual ch. 5) | Certifier and NPI; 30-day clock |
| KX status | CY 2026 KX threshold is $2,480 for PT and SLP combined, and $2,480 for OT (CMS) | Year-to-date amount from your eligibility source |
| Self-pay estimate | Self-pay patients scheduled 3+ business days ahead generally get a good faith estimate (CMS) | Estimate given and filed |
Sources: CMS Therapy Services page (2026); Medicare Claims Processing Manual ch. 5; APTA direct access summary (2023); UnitedHealthcare provider notice (January 2025); 45 CFR 156.115 (current 2026); CMS No Surprises Act consumer page (2026). Always check the member’s current plan.
Self-pay patients sit outside payer rules but still need clear pricing. CMS’s No Surprises Act page says uninsured and self-pay patients generally get a good faith estimate when they ask or schedule care at least 3 business days ahead, and may dispute a bill at least $400 above it. For Medicare patients likely to pass the threshold, CGS encourages an Advance Beneficiary Notice; see our ABN guide.
See what denials and missed visits cost you
Enter your claim volume and denial rate to estimate what your therapy practice is losing.
Therapy growth comes from patients searching for care and from physicians, surgeons and employers who refer. Your site still has to respect HIPAA.
We build condition and service pages, a plain referral page for physicians, and review requests that never confirm anyone is a patient. See our physical therapy practice growth guide and healthcare SEO guide. HHS guidance on online tracking says tools on appointment pages may collect protected health information and vendors that handle it need a Business Associate Agreement. A 2024 court order vacated part of that guidance; we still keep tracking off forms unless the vendor signs a BAA.
Stay in-house if your staff already count minutes and track signatures well. Use a billing-only vendor if claims are your only gap. Choose a combined partner when problems start at the front desk and end as denials.
| Job | In-house team | Billing-only vendor | Four-pillar partner (RCM Finder) |
|---|---|---|---|
| Timed units from total minutes | Rounded by habit | Coded from the note after the visit | Checked against documented minutes |
| Plan-of-care signatures | Whoever remembers | Often left to the practice | VMA tracks the due dates |
| Visit limits and authorizations | Front desk, between calls | Not included | VMA checks and logs before the evaluation |
| Assistant services (CQ, CO) | Depends on the notes | Billed as reported | Assistant minutes checked first |
| Patient and referral growth | A separate agency, or nobody | Not included | Marketing tied to booked evaluations |
| Cost structure | Salaries, benefits, turnover | Varies; ask how fees are set | Quoted after a free practice audit |
We start with a free audit and change nothing until you see the findings. We build our billing pipeline around how claims actually move through a practice: registration, charge entry, submission, payment and follow-up. For rehabilitation, we add the checks on this page.
We review recent therapy claims, denials, authorization logs and plan-of-care dates.
We put a Business Associate Agreement in place before accessing patient data. Then we work inside your existing EHR (for example PrognoCIS, eClinicalWorks or athenahealth).
Your main plans and your Medicare contractor’s guidance become a pre-visit checklist and portal rules.
VMAs check coverage, request approvals and track signatures. Claims are scrubbed, submitted and worked through denials and A/R.
We review denials by reason, A/R days, visits per authorization and plan-of-care deadlines.
Talk to us about your therapy practice
Tell us your disciplines and your hardest plan. We will tell you honestly whether we fit.
Any billing vendor that handles patient data is a HIPAA business associate. Get a Business Associate Agreement before access, and ask how access is limited and logged.
HHS guidance lists billing and claims processing as business associate work, and says subcontractors need their own agreement. The minimum necessary standard limits each use to what the task needs. The Security Rule’s technical safeguards cover access control, audit controls, integrity, person or entity authentication and transmission security.
We use role-based access, audit logging and encrypted (HTTPS) connections, and we put a Business Associate Agreement in place before accessing patient data. For your own side, use our HIPAA compliance checklist for medical practices.
We would rather tell you now than after you sign. Here is where we fit and where we do not.
A good fit if you are
Probably not a fit if you are
What we would do first if we were running your practice's revenue cycle tomorrow.
Units follow the day’s total timed minutes. We check each claim against them.
The 30-day, 10-visit and 90-day marks are easy to miss. We track them from the evaluation.
We request the visits and weeks that match the plan, then log the expiry.
CQ and CO depend on who gave how many minutes. We keep the split on the charge.
A modifier cannot rescue an undocumented pair. We check the intervals first.
Limits run out mid-plan. We flag the last approved visit before it is used.
They cover coding support, units from documented minutes, claim scrubbing, submission, denial management and A/R follow-up for therapy visits. A good partner also tracks plan-of-care signatures, authorizations and visit limits, and handles KX, CQ and CO. We add front-desk assistants, referral and patient marketing and a claims portal, so one team owns the process from the first call to payment, and we cover occupational and speech therapy the same way.
It is the common name for Medicare’s timed-unit table. In the Claims Processing Manual, 8 to 22 total timed minutes supports one unit, 23 to 37 supports two, and 38 to 52 supports three. Minutes are added across timed services for the day, and total timed minutes must be documented. Some commercial payers count units differently, so check each payer’s policy before applying the Medicare table.
For Medicare, the KX threshold for CY 2026 is $2,480 for PT and speech-language pathology combined and $2,480 for OT. Once a patient’s covered therapy passes it, claims need KX, which attests the services are reasonable, necessary and documented. Do not add KX automatically. Medicare also has a separate $3,000 targeted medical review threshold. Your Medicare contractor’s guidance may add detail.
CQ marks physical therapy furnished in whole or part by a physical therapist assistant. CO does the same for an occupational therapy assistant. Under CMS’s 10% test, the modifier applies when the assistant furnishes more than 10% of a service’s minutes. Medicare pays 85% of the otherwise applicable amount for those services, applied after the multiple procedure reduction. CQ must pair with GP and CO with GO.
It depends on the state and the payer. APTA’s September 2023 summary says 48 states allow evaluation and treatment without a referral, some with visit or day limits, while Alabama and Mississippi are limited. Medicare still requires a physician or nonphysician practitioner to certify the plan of care. Some commercial plans also want a referral, so verify the plan before the first visit.
Yes. Plans can set their own approval process, while following Medicare coverage criteria for basic benefits. UnitedHealthcare’s January 2025 notice, for example, asks for authorization of the whole plan of care for physical, occupational and speech therapy, and lets the first 6 visits in 8 weeks skip clinical review. Since 2026, CMS-0057-F requires Medicare Advantage plans to decide urgent requests within 72 hours and standard ones within seven calendar days.
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Pricing is quoted after the audit, based on your volume and the services you choose. Prefer to talk? Call +1 (302) 556-2288.
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