Medicare physical therapy coverage: codes, telehealth and limits
The short answerMedicare Part B pays physical therapists for 97161 to 97164, 97110, 97112, 97140 and 97530 under a physician-certified plan of care. Add GP to every line, and KX once the year passes $2,480 for 2026. CQ (PTA work) pays 85%.
By Javier Alvarez · Updated · 1 min read
1 row: Medicare. Public policy, not the member's benefits.
Medicare
Original Medicare (Part B), outpatient physical therapy · All states
| 97110 | Listed (timed, 15 minutes per unit) [1][2] |
|---|---|
| 97112 | Listed (timed, 15 minutes per unit) [1] |
| 97140 | Listed (timed, 15 minutes per unit) [1] |
| 97161 | Listed (evaluation, low complexity. One unit per episode of care.) [1][3] |
| 97162 | Listed (evaluation, moderate complexity. One unit per episode of care.) [1] |
| 97163 | Listed (evaluation, high complexity. One unit per episode of care.) [1] |
| 97164 | Limited (re-evaluation. Not routine during a planned course of therapy; use modifier 59 or XU only if the patient status changes.) [1][3] |
| 97530 | Listed (timed, 15 minutes per unit) [1] |
| Where it applies | Original Medicare Part B pays for outpatient physical therapy under a plan of care. Every therapy claim must carry the GP modifier to show it is a physical therapy plan of care. [2] |
| Other codes | Also priced in the 2026 file: 97164 re-evaluation, 97116 gait training, 97535 self-care training, 97542 wheelchair management and 97750 physical performance test. Remote therapeutic monitoring codes 98976, 98977, 98979, 98984 and 98985 are sometimes-therapy codes. [1][4] |
| Telehealth POS | Use POS 02 for telehealth when the patient is not at home and POS 10 when the patient is at home. Telehealth to a patient at home pays at the non-facility rate. [5] |
| Telehealth rules | Physical therapists can furnish Medicare telehealth, including the telephone assessment and management codes, through December 31, 2027. From January 1, 2028 they can no longer furnish Medicare telehealth under current law. Audio-only is allowed for patients in their homes through December 31, 2027. [4][5] |
| Visit limits | For 2026 the KX modifier threshold is $2,480 a year for PT and speech-language pathology combined (OT has its own $2,480). Claims above it without KX are denied. The targeted medical review threshold stays at $3,000 until 2028. [6][4] |
| Referral | A physician or NPP must certify the plan of care. Initial certification is due within 30 calendar days of the first treatment day, and recertification at least every 90 calendar days or when the plan changes significantly. Since January 1, 2025 a dated written order or referral can stand in for the signature on the initial plan if the signed plan is not returned in 30 days and the chart shows the plan was delivered. [2] |
| Who can bill | A physical therapist can bill Medicare directly after enrolling as a private practitioner (solo, partnership, group, physician or NPP group, or an incorporated therapy practice). Services go in the therapist's or group's office or in the patient's home. [7] |
| Payment | 2026 national amounts calculated from the CMS RVU file (total non-facility RVUs x $33.4009 conversion factor, before locality adjustment and the multiple procedure reduction): 97110 $29.06, 97112 $32.73, 97140 $27.72, 97530 $35.07, 97161 to 97163 $97.87 each, 97164 $67.47. [1] |
| Medicare rules | When a physical therapist assistant furnishes more than 10% of a service on their own, add CQ next to GP. Medicare pays CQ claims at 85% of the usual Part B amount. Do not use CQ when the PT does the whole service or when the PT and PTA treat together at the same time. [2] |
| Also | Timed codes follow the 8-minute rule: a single unit needs at least 8 minutes, and 23 minutes is the minimum for 2 units. The second and later therapy services on the same day get 50% of the practice expense component (MPPR). A progress report is needed at least once every 10 treatment days. [2][4] |
- CMS: PFS Relative Value Files, RVU26D (updated 08-26-2026), file PPRRVU2026_Oct_nonQPP, checked October 30, 2026
- CMS: MLN905365, Complying with Outpatient Rehabilitation Therapy Documentation Requirements (September 2025, PDF), checked October 30, 2026
- CMS: NCCI Medicare Policy Manual 2026, Chapter XI Medicine and E/M, 90000-99999 (rev. 1/1/2026, PDF), checked October 30, 2026
- CMS: Therapy Services landing page, CY 2026 Therapy Services Updates (KX threshold, MPPR, CQ/CO, telehealth), checked October 30, 2026
- CMS: Telehealth FAQ, updated 10/8/26 (PDF), checked October 30, 2026
- CMS: Transmittal 13437 (Change Request 14252) / Transmittal 13437, 2026 Annual Update of KX Modifier Thresholds (Oct 30, 2025, PDF), checked October 30, 2026
- CMS: Medicare Benefit Policy Manual, Chapter 15 (Rev. 13889, issued 07-30-26, PDF), checked October 30, 2026
What Medicare's documents say
The table above has every field we found for Medicare, with numbered sources. In short:
- Visit limits. For 2026 the KX modifier threshold is $2,480 a year for PT and speech-language pathology combined (OT has its own $2,480). Claims above it without KX are denied. The targeted medical review threshold stays at $3,000 until 2028.
- Who can bill. A physical therapist can bill Medicare directly after enrolling as a private practitioner (solo, partnership, group, physician or NPP group, or an incorporated therapy practice). Services go in the therapist's or group's office or in the patient's home.
- Telehealth rules. Physical therapists can furnish Medicare telehealth, including the telephone assessment and management codes, through December 31, 2027. From January 1, 2028 they can no longer furnish Medicare telehealth under current law. Audio-only is allowed for patients in their homes through December 31, 2027.
- Codes. 97110, 97112, 97140, 97161, 97162, 97163 and 97530 are listed. 97164 is limited.
Codes we checked at Medicare
What Medicare's own text says about one code: 97112, 97140, 97161 and 97164.
Physical therapy coverage at other national payers
UnitedHealthcare Medicare Advantage, UnitedHealthcare Commercial, Aetna, Cigna, Humana and TRICARE.
Check Medicare's claim against the row
Before the claim goes out, compare it with the row above: the evaluation code matches the complexity you documented, the timed codes fit the minutes, any prior authorization covers the visit, and the plan of care is signed when the payer asks for it. The physical therapy table compares Medicare with every other payer we checked.