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Physical Therapy Billing Guide: 2026 CPT Codes, Modifiers and Medicare Rules

First published November 9, 2026By Jacob Greenberg

Physical therapy claims are decided by a short list of facts in the record: which codes are timed and how many minutes each took, who furnished the service (a therapist or an assistant), whether the plan of care was certified on time, and how far the patient is into the year’s therapy spend. This guide gives the CPT code families, the Medicare modifiers that carry those facts (GP, CQ, KX and the NCCI distinct-service modifiers), and the documentation rules that decide whether the claim survives review.

Rules are quoted from CMS’s Medicare manuals, the Medicare NCCI Policy Manual chapter XI (revised January 1, 2026) and the CMS therapy services and telehealth pages; commercial and Medicare Advantage plans often follow Medicare but publish their own policies. If you want someone to run the claims rather than a code reference, see our physical therapy billing services page. Other specialties are in our billing and coding guides.

Quick answers

  • Timed codes are billed in 15-minute units; untimed codes are one unit per day however long they take.
  • GP goes on every physical therapy line. “Always therapy” codes without a therapy modifier are returned.
  • CQ marks PTA involvement and cuts the line to 85% of the fee schedule amount; it must be paired with GP.
  • KX starts at $2,480 of combined PT and SLP spend in 2026, and is an attestation the record has to support.
  • The plan of care is certified within 30 days, for up to 90 days, and progress reports are due at least every 10 treatment days.
  • MPPR cuts practice expense to 50% on every therapy unit after the first on the same day.

What changed for 2026, and what is set for 2027

ChangeWhat CMS publishedWhy it matters in physical therapy
KX modifier threshold$2,480 for PT and SLP combined; $2,480 for OT; targeted medical review threshold $3,000 (CMS Therapy Services page)The amount changes every January; check each patient’s year-to-date spend before the threshold is crossed
NCCI Policy Manual 2026Effective January 1, 2026 (CMS NCCI Policy Manual page)Chapter XI §P holds the physical medicine and rehabilitation edits
CY 2026 conversion factors$33.57 for qualifying APM participants and $33.40 for everyone else (CMS fact sheet, October 31, 2025)Two conversion factors now apply; check which one each therapist is paid under
Efficiency adjustment-2.5% on non-time-based services; CMS finalized a list of exempt codes, including time-based codes such as E/M (same fact sheet)Check whether each therapy code is on the exempt list rather than assuming
TelehealthPTs may furnish Medicare telehealth through December 31, 2027 (CMS Telehealth FAQ, October 8, 2026)Telehealth visits stay billable through 2027; plan for the January 1, 2028 end
CY 2027 conversion factors$32.95 qualifying APM and $32.63 non-qualifying, effective January 1, 2027 (CMS fact sheet, November 4, 2026)Both factors fall from 2026; the 2027 KX amount is published separately

Timed and untimed 97xxx code families

The Medicare Claims Processing Manual (chapter 5, §20.2 B) separates therapy codes into two kinds. An untimed code is not defined by a timeframe, so it is billed as one unit however long it took. A timed code is defined in 15-minute units of direct one-on-one contact, so the number of units comes from the minutes in the note.

FamilyCodesTimed?What it covers
PT evaluation97161, 97162, 97163Untimed, one unit per dayLow, moderate and high complexity evaluation
PT re-evaluation97164Untimed, one unit per dayRe-evaluation when the patient’s status changes
Supervised modalities97010–97028 (Medicare uses G0283 for unattended electrical stimulation)UntimedHot/cold packs, mechanical traction, unattended e-stim, whirlpool, paraffin, diathermy, infrared, ultraviolet
Constant-attendance modalities97032–97036Timed, each 15 minutesAttended e-stim, iontophoresis, contrast baths, ultrasound, Hubbard tank
Therapeutic procedures97110, 97112, 97116, 97140, 97530, 97535Timed, each 15 minutesExercise, neuromuscular re-education, gait training, manual therapy, therapeutic activities, self-care/home management
Tests and orthotics97750, 97760–97763Timed, each 15 minutesPhysical performance testing, orthotic and prosthetic management and training
Group therapy97150UntimedTwo or more patients treated at the same time

Turning minutes into units

Medicare totals the timed minutes for the day and converts the total into units, so the minutes of several timed codes are pooled; some commercial payers follow the AMA CPT method and count each code separately instead. The full chart, the AMA rule of eights comparison and worked examples are in our 8-minute rule guide.

GP, CQ and KX: the three Medicare therapy modifiers

ModifierUse it whenWhat happens without it
GPEvery line of a service delivered under a physical therapy plan of careClaims for “always therapy” codes without GN, GO or GP are returned (Claims Processing Manual ch. 5 §20)
CQThe service was furnished in whole or in part by a physical therapist assistantPaid at 100% when it should be 85%: an overpayment the practice owes back
KXThe patient’s year-to-date PT and SLP spend has passed the KX threshold and the services are medically necessaryLines above the threshold without KX are denied
59 / XUTwo timed codes in an NCCI edit pair were performed in different timed intervals, or a justified re-evaluationThe column-two code denies as bundled

CQ and the PTA payment differential

Since January 1, 2020, CQ is required on the line of any outpatient physical therapy service furnished in whole or in part by a PTA, alongside GP. Since January 1, 2022, those lines are paid at 85% of the otherwise applicable fee schedule amount (CMS Therapy Services page). The manual adds three details that billing staff get wrong:

  • Pairing is mandatory. CQ must be paired with GP; claims not so paired are rejected or returned as unprocessable.
  • Who it applies to. On professional claims, CQ applies to physical therapists in private practice, including a PT who has reassigned benefits to a physician group and is the rendering NPI. It does not apply to therapy furnished by or incident to a physician or NPP. On institutional claims it applies to outpatient hospitals, rehab agencies, SNFs, home health agencies and CORFs, but not to critical access hospitals.
  • Order of reductions. The 15% is taken last, after MPPR and other reductions and right before sequestration, from the paid amount.

KX and the $2,480 threshold

The KX threshold is not a cap: services above it are still paid when they are medically necessary and KX is on the line. The Claims Processing Manual (ch. 5 §10.3.3) says that by appending KX the provider attests the services are reasonable and necessary and require the skills of a therapist, are justified by appropriate documentation in the medical record, and qualify for the exception. Adding KX when nothing suggests the threshold will be passed is called abusive in the same section. Past $3,000 a claim can be selected for targeted medical review, which is when the plan of care, progress reports and treatment notes are read line by line.

Plan of care: certification and recertification

Outpatient therapy is payable under Medicare only under a plan of care certified by a physician or NPP. The Medicare Benefit Policy Manual chapter 15 §220.1 sets the clock:

EventRule
Initial certificationSigned or verbally ordered and dated within 30 days of the first treatment day, which includes the evaluation. A verbal order must be followed by a signature within 14 days.
Duration certifiedWhatever the physician or NPP finds appropriate, up to 90 calendar days from the initial treatment
RecertificationAt least every 90 days after treatment starts under the plan, or whenever the plan needs a significant modification
Delayed certificationAccepted at any later date when it comes with a reason for the delay; acceptable without justification for 30 days after it was due
No recertification neededWhen the certified duration is longer than the whole episode of care

The therapist should send the plan to the physician as soon as it is written: payment may be denied when the plan is never certified, and evidence of diligence is considered when a certification is late.

The progress report every 10 treatment days

Benefit Policy Manual §220.3 D sets the minimum progress report period at once every 10 treatment days. The first period begins on the first day of the episode, whether that day was an evaluation, re-evaluation or treatment. A treatment day is a calendar day on which the patient was treated; holidays and absences do not count as treatment days but do not remove the need for a report in each period.

  • Who writes it. The physician or NPP who provides or supervises the services, or the therapist who provides the services and supervises an assistant. A PTA’s note does not satisfy the requirement.
  • Recertification does not reset it. CMS states the recertification dates do not affect the progress report dates; there may be several reports between recertifications.
  • A report can come early. The clinician may end a reporting period before the 10th treatment day, and the next treatment day starts a new period.

Multiple procedure payment reduction (MPPR)

Claims Processing Manual ch. 5 §10.7: Medicare ranks the “always therapy” services furnished to one patient on one day by practice-expense RVU, pays the highest in full, and for every other unit and procedure pays full work and malpractice but 50% of the practice expense. That applies to dates of service on or after April 1, 2013, on professional and institutional claims alike.

  • MPPR applies to multiple units of one code as well as to multiple codes.
  • It applies across disciplines: a PT visit and an OT visit for the same patient on the same day are ranked together.
  • It does not apply to contractor-priced, bundled and add-on codes.
  • A lower allowed amount on the second and later units is MPPR working as designed, not an underpayment to appeal.

NCCI edits for physical medicine and rehabilitation

RuleWhat the 2026 NCCI manual saysNCCI ch. XI
One evaluation per dayA physical therapist may report only one evaluation or re-evaluation (97161–97164) on a date of service§P.1
One service per 15 minutesNo more than one therapy service for the same 15-minute period, except supervised modalities 97010–97028. Timed pairs done in different intervals may be bypassed with 59 or XU§P.2
Re-evaluation97164 is not reported routinely during a planned course of therapy; when status changes, append 59 or XU to 97164§P.3
Tests with an evaluation97750, 97755 and 97763 are not separately reportable with 97161–97164 on the same day by one practitioner or two of the same specialty§P.8
Wound care97597–97602 are not reported with surgical debridement 11042–11047 for the same wound§P.6
Cardiac and pulmonary rehabPT at the same encounter as cardiac or pulmonary rehabilitation is included in that benefit§P.7

NCCI does not contain every edit pair that the 15-minute rule implies, and the manual says physicians are expected to code correctly even when no edit fires (§P.2).

Telehealth for physical therapy

CMS’s Telehealth FAQ (updated October 8, 2026) answers the question practices ask most:

  • Through December 31, 2027 an extended range of practitioners, including physical therapists, may bill Medicare telehealth, and patients may be anywhere in the United States.
  • From January 1, 2028 physical therapists, occupational therapists, speech-language pathologists and audiologists can no longer furnish Medicare telehealth services under current law.
  • The October 2025 lapse is closed. CMS pays telehealth claims as they were paid before October 1, 2025, with the flexibilities applied retroactively.
  • Place of service: POS 10 for the patient’s home, POS 02 for other locations; home telehealth is paid at the non-facility rate.
  • New in 2027: modifiers BB (virtual platform arrangements) and BC (incident-to telehealth) are required from January 1, 2027, with no payment effect.

Common physical therapy denials and what causes them

What the payer didUsual causeRule behind it
Returned the claimA therapy line without GP, or CQ not paired with GPClaims Processing Manual ch. 5 §20 and CQ/CO section
Denied lines late in the yearPatient past the $2,480 KX threshold and KX not on the lineCMS Therapy Services page; ch. 5 §10.3.3
Denied or recouped on reviewPlan of care never certified, or certified late with no reason givenBenefit Policy Manual ch. 15 §220.1
Denied on review for medical necessityNo progress report in a 10-treatment-day period, or one written only by a PTABenefit Policy Manual ch. 15 §220.3
Bundled a timed codeTwo timed codes billed for the same 15 minutes, or 59/XU missing when the intervals were differentNCCI ch. XI §P.2
Bundled 97164 or 97750Routine re-evaluation, or a test billed with the evaluation the same dayNCCI ch. XI §P.3, §P.8
Units reducedUnits billed per code when Medicare counts total timed minutesClaims Processing Manual ch. 5 §20.2

Working these back to paid, with the record pulled and the right modifier or certification attached, is what our denial management service does.

Sources

CPT codes and descriptors are from the AMA CPT code set. This guide does not state fee amounts; check your Medicare contractor’s fee schedule and your payer contracts.

Frequently asked questions

What is the KX modifier threshold for physical therapy in 2026?

For calendar year 2026 the KX modifier threshold is $2,480 for physical therapy and speech-language pathology services combined, and a separate $2,480 for occupational therapy. Above the threshold, medically necessary services are billed with KX; claims above it without KX are denied. The targeted medical review threshold is $3,000.

What does the KX modifier attest?

Under the Medicare Claims Processing Manual, appending KX attests that the services are reasonable and necessary and require the skills of a therapist, are justified by documentation in the medical record, and qualify for the exception. An inaccurate attestation exposes the provider to sanctions, so KX is never added to every line by default.

How much less does Medicare pay when a PTA provides the service?

Services furnished in whole or in part by a physical therapist assistant carry the CQ modifier and are paid at 85% of the otherwise applicable fee schedule amount, for dates of service on or after January 1, 2022. CMS takes the 15% reduction last, after the multiple procedure payment reduction. CQ must be paired with GP or the claim is rejected.

Which physical therapy codes are timed and which are untimed?

Evaluations and re-evaluations (97161 to 97164), supervised modalities (97010 to 97028) and group therapy (97150) are untimed and billed as one unit regardless of minutes. Constant-attendance modalities (97032 to 97036) and procedures such as 97110, 97112, 97116, 97140, 97530 and 97535 are timed in 15-minute units.

How often does a Medicare plan of care need to be recertified?

The physician or NPP certifies the initial plan within 30 days of the first treatment, which includes the evaluation. A plan can be certified for up to 90 calendar days, and recertification is due at least every 90 days or when the plan changes significantly. Late certifications are accepted when they carry a reason for the delay.

When is a physical therapy progress report due?

At least once every 10 treatment days. The first period starts on the first day of the episode, evaluation included. The report must be written by the therapist (or the physician or NPP), not by the assistant, and recertification dates do not reset the 10-day count.

What is MPPR in physical therapy billing?

The multiple procedure payment reduction pays the unit or procedure with the highest practice expense in full, then pays 50% of the practice expense portion for every other unit and procedure of "always therapy" codes for the same patient on the same day. Work and malpractice are paid in full. It applies across PT, OT and SLP and to both professional and institutional claims.

Can physical therapists bill Medicare telehealth in 2026?

Yes. CMS's telehealth FAQ (updated October 8, 2026) says physical therapists, occupational therapists, speech-language pathologists and audiologists may furnish Medicare telehealth through December 31, 2027. Starting January 1, 2028 they can no longer furnish Medicare telehealth services unless the law changes.

Can a re-evaluation be billed during an ongoing plan of care?

Only when the patient's status changes and a re-evaluation is medically necessary. The 2026 NCCI manual says 97164 is not to be reported routinely during a planned course of therapy; when it is justified, modifier 59 or XU goes on 97164 to bypass the edit with the treatment codes.

Guides for other specialties are listed in our billing and coding guides.

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