Rehabilitation therapy billing for occupational, speech and physical therapy practices: evaluations and plans of care, timed codes under the 8-minute rule, the KX threshold, therapy modifiers, assistant services and telehealth, worked inside the software you already use.
Therapy billing is paid by the unit and controlled by the plan of care. Each visit’s timed minutes are converted to units under the payer’s rule, the plan of care is certified and recertified on time, the right discipline modifier and any KX or assistant modifier are added, and every payment and denial is followed until it is resolved.
$54M
in improper Medicare payments to occupational therapists in private practice in CMS’s 2025 review, a 12.8% improper payment rate
$2,480
the 2026 Medicare threshold above which therapy claims need modifier KX, for PT and speech combined and for OT on its own
Sources: CMS, 2025 Medicare Fee-for-Service Supplemental Improper Payment Data, November 2025; CMS Change Request 13437 (2026 therapy threshold)
Most therapy codes are timed, so the minutes in the note decide the units. Medicare adds a certified plan of care, a yearly threshold above which every claim needs modifier KX, and a lower payment when an assistant furnishes part of the service. Each discipline is billed with its own modifier, and occupational therapy has a separate threshold from physical and speech therapy.
The minutes and the plan of care decide the claim. That is why we check the timed minutes, the plan of care dates and each patient’s running total against the threshold before claims go out.
Therapy practices bill evaluations once and treatment many times, under rules that change as a patient’s care goes on. Each card shows where the claim fails and what we change.
Pays forEvaluations and re-evaluations, and the plan of care the physician or practitioner certifies.
Where it breaks
What we do
Pays forTherapeutic exercise, activities, self-care training, manual therapy and other timed services, by the unit.
Where it breaks
What we do
Pays forTherapy above the yearly threshold, services by assistants, and telehealth visits.
Where it breaks
What we do
Medicare no longer caps outpatient therapy, but it sets a yearly amount above which each claim must carry modifier KX to confirm the services are medically necessary and documented. For 2026, the threshold is $2,480 for physical therapy and speech-language pathology combined, and a separate $2,480 for occupational therapy. Above $3,000, claims can be selected for targeted medical review, a rule that runs through 2028.
Every Medicare therapy patient needs a plan of care certified by a physician or nonphysician practitioner, signed within 30 days of the first treatment, and recertified at least every 90 days or when the plan changes significantly. Without a current certification, the visits after it lapsed are not payable.
What we do: we track each patient’s running total for the year by discipline and add KX when it passes the threshold and the record supports it. We also track plan of care dates, so certifications and recertifications are sent before they lapse.
Therapy claims combine untimed evaluations with timed treatment codes. These are the ones we see most in occupational, speech and physical therapy, with what payers check on each.
| Code | What it covers | What payers look for |
|---|---|---|
| 97165 to 97167 | Occupational therapy evaluations, low to high complexity | Untimed; the complexity documented. |
| 97161 to 97163 | Physical therapy evaluations, low to high complexity | Untimed; the complexity documented. |
| 92521 to 9252492610 | Speech, language, voice and swallowing evaluations | The type of evaluation and the findings. |
| 9250792526 | Speech and swallowing treatment | Untimed, billed once per session. |
| 9711097530 | Therapeutic exercise and therapeutic activities | Timed; minutes for each and the total. |
| 97535 | Self-care and home management training | Timed; the activities of daily living addressed. |
| 9714097112 | Manual therapy and neuromuscular re-education | Timed; separate regions or documented need with paired codes. |
Physical, occupational or speech therapy, on every therapy line.
Medicare: the patient's yearly total is above the threshold and the services are necessary.
A physical or occupational therapy assistant furnished more than 10% of the service; paid at 85%.
Paired codes, such as manual therapy and therapeutic activities, done separately. Our modifier 59 guide
Therapy by video, for plans and dates that allow it.
Medicare: services that may not be covered, with a signed notice.
Sources: Medicare Benefit Policy Manual, chapter 15, section 220; Medicare Claims Processing Manual, chapter 5; CMS Telehealth FAQ (26 February 2026). CPT is a registered trademark of the American Medical Association; the descriptions above are summaries. Reviewed October 2026.
It is not for every practice. If you are a hospital-employed group whose billing the hospital handles, you do not need us. And if your in-house team keeps denials low and receivables current, keep them, and consider a periodic billing audit instead.
We look at your clean-claim rate, your denials by payer and reason, timed units, plan of care dates, the KX threshold and therapy modifiers, and your aging receivables, and tell you what we find, whether or not you go further with us.
We get access to your practice management system and clearinghouse, load each payer's authorization and bundling rules and your fee schedules, list active patients with their plan of care dates and yearly totals, and agree how escalations work. Most practices are live within one to two weeks.
Evaluations and treatment minutes are coded and claims submitted within 24 hours. Rejections are corrected the same day, remittances posted as they arrive, units, plan of care dates and thresholds checked, and denials worked to their cause, all inside your system.
A report you can read in ten minutes: what was billed and collected by payer, site and service line, what was denied and why, authorizations pending, and what is aging.
You do not change systems to work with Summit Billing Solutions. We work in the practice management and EHR systems below, and through the clearinghouse you already use. If your EHR is not shown, ask; the list grows as we onboard practices.
95-98%
First-pass claim rate
24 hrs
Claims submitted within
28
Average days in A/R
Therapy practices bill many visits per patient, each worth a modest amount, and a lapsed plan of care can stop payment on all of them. A fee based on collections keeps our attention on every visit being paid, not just billed.
Summit Billing Solutions charges between 3% and 9% of monthly collections. Your rate depends on visit volume, your mix of occupational, speech and physical therapy, your Medicare share and the state of the receivables, which we see in the free account review.
3% to 9%
of monthly collections
We bill for more than 40 specialties, for practices in all 50 states, from Salem, New Hampshire. Each one has its own codes, modifiers and payer rules.
A free account review looks at your clean-claim rate, your denials by payer and reason, timed units, plan of care dates, the KX threshold and therapy modifiers, and your aging receivables, and tells you what we would change. No cost, no obligation, and no pressure to continue. What the review covers, step by step, is on the free account review page.
50A Northwestern Dr Ste 3, Salem, NH 03079-4827
603-207-3172
(866) 906-3116
info@summitbillingsolutions.com
Mon - Fri @ 9am - 5pm
