{ "name": "Eobify Therapy Billing Unit Rules", "title": "Therapy Billing Unit Rules", "url": "https://eobify.com/datasets/therapy-billing-unit-rules/", "csv": "https://eobify.com/datasets/therapy-billing-unit-rules.csv", "markdown": "https://eobify.com/datasets/therapy-billing-unit-rules/index.md", "computed_at": "2026-10-19", "license": "https://eobify.com/terms", "headline": "The Therapy Billing Unit Rules carries 11 published figures read from 5 sources' own pages, from 2,150 to 3,000 USD, read 18 October 2026.", "quotes": [ "The Therapy Billing Unit Rules carries 11 published figures read from 5 sources' own pages, from 2,150 to 3,000 USD, read 18 October 2026.", "5 of the 7 named sources read in full publish a figure; 2 publish none, read 18 October 2026.", "Therapy Billing Unit Rules, year 2026: median 2,480 USD across 3 sources, read 18 October 2026.", "Therapy Billing Unit Rules, year 2025: median 2,410 USD across 1 source, read 18 October 2026.", "Therapy Billing Unit Rules, year 2024: median 2,330 USD across 1 source, read 18 October 2026.", "Therapy Billing Unit Rules, year 2023: median 2,230 USD across 1 source, read 18 October 2026.", "Therapy Billing Unit Rules, year 2022: median 2,150 USD across 1 source, read 18 October 2026.", "Therapy Billing Unit Rules, rule targeted-medical-review: median 3,000 USD across 4 sources, read 18 October 2026.", "Therapy Billing Unit Rules, rule mppr-rate: median 50 percent across 1 source, read 18 October 2026.", "Therapy Billing Unit Rules, rule pta-ota-payment-rate: median 85 percent across 1 source, read 18 October 2026.", "Therapy Billing Unit Rules, rule de-minimis-standard: median 10 percent across 1 source, read 18 October 2026.", "Therapy Billing Unit Rules, rule coinsurance: median 20 percent across 1 source, read 18 October 2026." ], "citation": "\"Eobify Therapy Billing Unit Rules\", updated 2026-10-19, https://eobify.com/datasets/therapy-billing-unit-rules/.", "changed_since": null, "national": { "unit": "USD", "n": 11, "median": 2480, "min": 2150, "max": 3000, "p25": 2330, "p75": 3000, "mean": 2596.3636, "units": { "%": 4, "USD": 11 }, "published_sources": 5, "named_sources": 7, "read_sources": 7, "not_published": 2, "published_share": 0.714 }, "by_axis": { "year": { "2022": { "USD": { "n": 1, "median": 2150, "min": 2150, "max": 2150, "p25": 2150, "p75": 2150, "mean": 2150 } }, "2023": { "USD": { "n": 1, "median": 2230, "min": 2230, "max": 2230, "p25": 2230, "p75": 2230, "mean": 2230 } }, "2024": { "USD": { "n": 1, "median": 2330, "min": 2330, "max": 2330, "p25": 2330, "p75": 2330, "mean": 2330 } }, "2025": { "USD": { "n": 1, "median": 2410, "min": 2410, "max": 2410, "p25": 2410, "p75": 2410, "mean": 2410 } }, "2026": { "USD": { "n": 3, "median": 2480, "min": 2480, "max": 2480, "p25": 2480, "p75": 2480, "mean": 2480 } } }, "rule": { "targeted-medical-review": { "USD": { "n": 4, "median": 3000, "min": 3000, "max": 3000, "p25": 3000, "p75": 3000, "mean": 3000 } }, "mppr-rate": { "%": { "n": 1, "median": 50, "min": 50, "max": 50, "p25": 50, "p75": 50, "mean": 50 } }, "pta-ota-payment-rate": { "%": { "n": 1, "median": 85, "min": 85, "max": 85, "p25": 85, "p75": 85, "mean": 85 } }, "de-minimis-standard": { "%": { "n": 1, "median": 10, "min": 10, "max": 10, "p25": 10, "p75": 10, "mean": 10 } }, "coinsurance": { "%": { "n": 1, "median": 20, "min": 20, "max": 20, "p25": 20, "p75": 20, "mean": 20 } } } }, "rows": [ { "source": "APTA, Medicare payment thresholds for outpatient therapy", "url": "https://www.apta.org/your-practice/payment/medicare-payment/coding-billing/therapy-cap", "figure": "$2,480 ", "value": 2480, "unit": "USD", "vat": null, "axis": { "year": "2026" }, "retrieved_at": "2026-10-17", "quote": "For CY 2026 this KX modifier threshold amount is: $2,480 for PT and SLP services combined, and", "source_class": "first-party-index", "text_sha256": "1ed7ba806397b9ae91e545d6aa919b4e0440eb183cd62f7626dd2149cddee00f" }, { "source": "APTA, Medicare payment thresholds for outpatient therapy", "url": "https://www.apta.org/your-practice/payment/medicare-payment/coding-billing/therapy-cap", "figure": "$2,410 ", "value": 2410, "unit": "USD", "vat": null, "axis": { "year": "2025" }, "retrieved_at": "2026-10-17", "quote": "For CY 2025 this KX modifier threshold amount is: $2,410 for PT and SLP services combined, and", "source_class": "first-party-index", "text_sha256": "1ed7ba806397b9ae91e545d6aa919b4e0440eb183cd62f7626dd2149cddee00f" }, { "source": "APTA, Medicare payment thresholds for outpatient therapy", "url": "https://www.apta.org/your-practice/payment/medicare-payment/coding-billing/therapy-cap", "figure": "$2,330 ", "value": 2330, "unit": "USD", "vat": null, "axis": { "year": "2024" }, "retrieved_at": "2026-10-17", "quote": "For CY 2024 this KX modifier threshold amount is: $2,330 for PT and SLP services combined, and", "source_class": "first-party-index", "text_sha256": "1ed7ba806397b9ae91e545d6aa919b4e0440eb183cd62f7626dd2149cddee00f" }, { "source": "APTA, Medicare payment thresholds for outpatient therapy", "url": "https://www.apta.org/your-practice/payment/medicare-payment/coding-billing/therapy-cap", "figure": "$2,230 ", "value": 2230, "unit": "USD", "vat": null, "axis": { "year": "2023" }, "retrieved_at": "2026-10-17", "quote": "For 2023 this KX modifier threshold amount is: $2,230 for PT and SLP services combined, and", "source_class": "first-party-index", "text_sha256": "1ed7ba806397b9ae91e545d6aa919b4e0440eb183cd62f7626dd2149cddee00f" }, { "source": "APTA, Medicare payment thresholds for outpatient therapy", "url": "https://www.apta.org/your-practice/payment/medicare-payment/coding-billing/therapy-cap", "figure": "$2,150 ", "value": 2150, "unit": "USD", "vat": null, "axis": { "year": "2022" }, "retrieved_at": "2026-10-17", "quote": "For 2022 this KX modifier threshold amount is: $2,150 for PT and SLP services combined, and", "source_class": "first-party-index", "text_sha256": "1ed7ba806397b9ae91e545d6aa919b4e0440eb183cd62f7626dd2149cddee00f" }, { "source": "APTA, Medicare payment thresholds for outpatient therapy", "url": "https://www.apta.org/your-practice/payment/medicare-payment/coding-billing/therapy-cap", "figure": "$3,000 ", "value": 3000, "unit": "USD", "vat": null, "axis": { "rule": "targeted-medical-review" }, "retrieved_at": "2026-10-17", "quote": "For 2018 through 2028, the targeted medical review threshold is $3,000 for PT and SLP services, and $3,000 for OT services.", "source_class": "first-party-index", "text_sha256": "1ed7ba806397b9ae91e545d6aa919b4e0440eb183cd62f7626dd2149cddee00f" }, { "source": "WebPT Medicare physical therapy cap guide", "url": "https://www.webpt.com/guides/therapy-cap", "figure": "$2,480 ", "value": 2480, "unit": "USD", "vat": null, "axis": { "year": "2026" }, "retrieved_at": "2026-10-17", "quote": "That means therapists must continue to track their patients’ progress toward the threshold each year—and affix the KX modifier to all claims for medically necessary services that exceed this threshold (in 2026, the threshold is $2,480 for PT and speech language pathology (SLP) services combined and $2,480 for OT services for the calendar year).", "source_class": "primary-provider-own-site", "text_sha256": "40fb54b19da8e2b5d5ebf67d618b568718f04c36f0acd0f40110ae19f1191b5e" }, { "source": "WebPT Medicare physical therapy cap guide", "url": "https://www.webpt.com/guides/therapy-cap", "figure": "$3,000 ", "value": 3000, "unit": "USD", "vat": null, "axis": { "rule": "targeted-medical-review" }, "retrieved_at": "2026-10-17", "quote": "After all, Congress did not increase funding for claim reviews.” The current targeted medical review threshold of $3,000 will remain in place until at least 2028.", "source_class": "primary-provider-own-site", "text_sha256": "40fb54b19da8e2b5d5ebf67d618b568718f04c36f0acd0f40110ae19f1191b5e" }, { "source": "CMS therapy services: coding and billing, KX threshold", "url": "https://www.cms.gov/medicare/coding-billing/therapy-services", "figure": "50 percent", "value": 50, "unit": "%", "vat": null, "axis": { "rule": "mppr-rate" }, "retrieved_at": "2026-10-17", "quote": "Since April 1, 2013, the MPPR rate is 50 percent for both practitioner/office and institutional settings.", "source_class": "primary-government", "text_sha256": "23553a2a82fb37489775f05fefe1a6e6e2120b29776a3ceec56b491751869e77" }, { "source": "CMS therapy services: coding and billing, KX threshold", "url": "https://www.cms.gov/medicare/coding-billing/therapy-services", "figure": "$2,480 ", "value": 2480, "unit": "USD", "vat": null, "axis": { "year": "2026" }, "retrieved_at": "2026-10-17", "quote": "For CY 2026 this KX modifier threshold amount is: $2,480 for PT and SLP services combined, and", "source_class": "primary-government", "text_sha256": "23553a2a82fb37489775f05fefe1a6e6e2120b29776a3ceec56b491751869e77" }, { "source": "CMS therapy services: coding and billing, KX threshold", "url": "https://www.cms.gov/medicare/coding-billing/therapy-services", "figure": "$3,000.", "value": 3000, "unit": "USD", "vat": null, "axis": { "rule": "targeted-medical-review" }, "retrieved_at": "2026-10-17", "quote": "Along with this KX modifier threshold, the BBA of 2018 retains the targeted medical review (MR) process (first established through Section 202 of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)), but at a lower threshold amount of $3,000.", "source_class": "primary-government", "text_sha256": "23553a2a82fb37489775f05fefe1a6e6e2120b29776a3ceec56b491751869e77" }, { "source": "CMS therapy services: coding and billing, KX threshold", "url": "https://www.cms.gov/medicare/coding-billing/therapy-services", "figure": "85 percent", "value": 85, "unit": "%", "vat": null, "axis": { "rule": "pta-ota-payment-rate" }, "retrieved_at": "2026-10-17", "quote": "Payment for these services is at 85 percent of the otherwise applicable PFS payment amount/rate for the service, effective January 1, 2022.", "source_class": "primary-government", "text_sha256": "23553a2a82fb37489775f05fefe1a6e6e2120b29776a3ceec56b491751869e77" }, { "source": "CMS billing examples using CQ/CO modifiers for PTA and OTA services", "url": "https://www.cms.gov/medicare/therapy-services/billing-examples-using-cqco-modifiers-services-furnished-whole-or-part-ptas-and-otas", "figure": "10 percent", "value": 10, "unit": "%", "vat": null, "axis": { "rule": "de-minimis-standard" }, "retrieved_at": "2026-10-17", "quote": "the PTA/OTA furnishes a portion of a service (or unit of service) separately from the part that is furnished by the PT/OT, such that the minutes for that portion of a service (or unit of a service) furnished by the PTA/OTA exceed 10 percent of the total minutes for that service (or unit of a service) ─ except in the specific cases that are outlined below.", "source_class": "primary-government", "text_sha256": "62b5bd1eaa93c5dea03ec8c16c96d91b6ccabc7c31b6f4de0ed05202dd5b6c98" }, { "source": "Medicare Claims Processing Manual chapter 5 (the 8-minute rule for timed codes)", "url": "https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/clm104c05.pdf", "figure": "20 percent", "value": 20, "unit": "%", "vat": null, "axis": { "rule": "coinsurance" }, "retrieved_at": "2026-10-18", "quote": "charge after the Part B deductible is met. Coinsurance is made at 20 percent of the lower", "source_class": "primary-government", "text_sha256": "1b7066a91f120dd3ca6f56f11566598d5dddfb0dbb14618c8aa91a961be17676" }, { "source": "Medicare Claims Processing Manual chapter 5 (the 8-minute rule for timed codes)", "url": "https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/clm104c05.pdf", "figure": "$3,000 ", "value": 3000, "unit": "USD", "vat": null, "axis": { "rule": "targeted-medical-review" }, "retrieved_at": "2026-10-18", "quote": "MEI), the MR threshold is $3,000 for PT and SLP services and $3,000 for OT services.", "source_class": "primary-government", "text_sha256": "1b7066a91f120dd3ca6f56f11566598d5dddfb0dbb14618c8aa91a961be17676" } ], "not_published": [ { "source": "42 CFR 424.44, time limits for filing claims (eCFR, current)", "url": "https://www.ecfr.gov/current/title-42/section-424.44", "retrieved_at": "2026-10-12", "reason": "read in full and no accepted figure on the page" }, { "source": "CMS MM12397, reduced payment for PT and OT furnished in whole or part by assistants", "url": "https://www.cms.gov/files/document/mm12397-reduced-payment-physical-therapy-and-occupational-therapy-services-furnished-whole-or-part.pdf", "retrieved_at": "2026-09-20", "reason": "read in full and no accepted figure on the page" } ], "sources": [ { "url": "https://www.cms.gov/medicare/coding-billing/therapy-services", "label": "CMS therapy services: coding and billing, KX threshold", "license": "the publisher's own terms; quoted for reporting and comment" }, { "url": "https://www.cms.gov/medicare/therapy-services/billing-examples-using-cqco-modifiers-services-furnished-whole-or-part-ptas-and-otas", "label": "CMS billing examples using CQ/CO modifiers for PTA and OTA services", "license": "the publisher's own terms; quoted for reporting and comment" }, { "url": "https://www.ecfr.gov/current/title-42/section-424.44", "label": "42 CFR 424.44, time limits for filing claims (eCFR, current)", "license": "the publisher's own terms; quoted for reporting and comment" }, { "url": "https://www.apta.org/your-practice/payment/medicare-payment/coding-billing/therapy-cap", "label": "APTA, Medicare payment thresholds for outpatient therapy", "license": "the publisher's own terms; quoted for reporting and comment" }, { "url": "https://www.webpt.com/guides/therapy-cap", "label": "WebPT Medicare physical therapy cap guide", "license": "the publisher's own terms; quoted for reporting and comment" }, { "url": "https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/clm104c05.pdf", "label": "Medicare Claims Processing Manual chapter 5 (the 8-minute rule for timed codes)", "license": "the publisher's own terms; quoted for reporting and comment" }, { "url": "https://www.cms.gov/files/document/mm12397-reduced-payment-physical-therapy-and-occupational-therapy-services-furnished-whole-or-part.pdf", "label": "CMS MM12397, reduced payment for PT and OT furnished in whole or part by assistants", "license": "the publisher's own terms; quoted for reporting and comment" } ], "methodology": "Every row is a verbatim sentence read from the named source's own page through our fetch service on the date shown, hash-pinned to the stored read (the sha of the page's visible text; the raw page is mirrored to R2). 5 of the 7 named sources that could be read published a usable figure; 2 published none and are recorded as not published, never filled in; 0 could not be read (blocked, dead or unreachable) and count nowhere. The headline figures (median, minimum, maximum, quartiles) are over ONE figure per source for each breakdown it prices, in USD (a source's median where its page yielded several accepted sentences for one breakdown), so a page that gives figures for several breakdowns gives one for each and N counts 11 figures, never sentences; 18 candidate sentence(s) were refused by a reviewer with the reason recorded. The fuller derivation this dataset is chartered to grow into (not yet what the figures above are; they are each source's own published figure as read): one row per rule per year: the 8-minute-rule unit table (minutes to units, verbatim from the Medicare Claims Processing Manual), the CQ and CO assistant modifiers with the 15% differential and the greater-than-10% test, the KX threshold and the targeted-medical-review threshold with their dollar amounts per year, and the filing deadline - each with its effective date and the year-on-year change, so a practice sees what moved rather than a static explainer", "embed": "

2,150 to 3,000 USD

11 published figures, Therapy Billing Unit Rules, across 5 sources, read 18 October 2026

Source: Eobify Therapy Billing Unit Rules
" }