In 2026, once a patient’s Medicare allowed amounts for the year pass $2,480 for PT and speech combined, or $2,480 for OT, every further claim line needs the KX modifier, which confirms the services are medically necessary and the record supports it. Claims over the threshold without KX are denied. Above $3,000, claims may be selected for targeted medical review. At national rates a typical patient reaches the KX threshold around visit 25.
The two thresholds
Medicare used to cap outpatient therapy. Section 50202 of the Bipartisan Budget Act of 2018 repealed the caps and the exceptions process but kept the amounts as thresholds, indexed each year by the Medicare Economic Index (CMS).
| Threshold, 2026 | PT and speech (combined) | OT | What happens above it |
|---|---|---|---|
| KX threshold | $2,480 | $2,480 | KX modifier required on each claim line; claims without it are denied |
| Medical review threshold | $3,000 | $3,000 | Claims may be selected for targeted medical review |
Amounts are per patient, per calendar year, counted in Medicare allowed amounts (after the multiple procedure reduction), not your charges, and across every provider the patient sees.
Check a patient now
Enter a patient’s allowed amounts so far this year and a typical visit amount:
This patient, 2026
Under $2,480. No KX modifier is needed yet. $630 remains before it is required.
Physical therapy and speech-language pathology share one amount. Thresholds apply per patient per calendar year, across all providers. Use the allowed amount, not your billed charge.
How many visits it takes
Using CMS’s 2026 rates, a patient with an evaluation day (97162 plus two units of 97110) followed by typical four-unit visits (two 97110, one 97140, one 97530) reaches the thresholds here:
| Area | Typical visit | Reaches KX at | Reaches review at |
|---|---|---|---|
| National average | $100.70 | Visit 25 | Visit 30 |
| Highest-paid area (Alaska) | $132.28 | Visit 19 | Visit 23 |
| Lowest-paid area (Arkansas) | $94.38 | Visit 26 | Visit 32 |
Shorter visits or more modalities push these later; longer visits and evaluations pull them earlier. Run your own visit in the rate calculator and divide the remaining amount by it.
Watching the line get crossed
Here are the last few visits of the national example, showing the running total before and after each one. The KX modifier is needed from the first visit whose services take the total over $2,480.
| Visit | Allowed this visit | Total before | Total after | KX? |
|---|---|---|---|---|
| 22 | $100.70 | $2,156.29 | $2,256.99 | No |
| 23 | $100.70 | $2,256.99 | $2,357.69 | No |
| 24 | $100.70 | $2,357.69 | $2,458.39 | No |
| 25 | $100.70 | $2,458.39 | $2,559.09 | Yes |
| 26 | $100.70 | $2,559.09 | $2,659.79 | Yes |
More than one discipline: worked numbers
PT and speech share one amount; OT has its own. At national 2026 rates, a speech session (92507) is $76.15 and a three-unit OT visit (two 97530, one 97535) is about $84.00:
| Plan | Allowed per week | Counts toward | Weeks to $2,480 |
|---|---|---|---|
| PT only, 2 visits a week | $201.40 | PT/speech | About 13 |
| PT 2× + speech 2× a week | $353.70 | PT/speech | About 8 |
| OT only, 2 visits a week | $168.00 | OT | About 15 |
Adding twice-weekly speech brings the PT/speech threshold weeks closer. A clinic offering both needs one shared running total for the two disciplines, and a separate one for OT.
Ten quick facts
- The thresholds are per patient, per calendar year.
- They count Medicare allowed amounts, after the multiple procedure reduction.
- They include every provider’s therapy for that patient that year.
- PT and speech share one amount; OT has its own.
- KX is required on lines above the threshold; lines without it are denied.
- KX confirms medical necessity supported by the record.
- There is no hard cap and no exceptions request any more.
- Above $3,000, review is targeted, not automatic.
- The KX amount is indexed each year; the review amount from 2028.
- Medicare Advantage plans follow their own rules.
What KX attests
Adding KX is your confirmation that the services are medically necessary and that the medical record justifies them (CMS). It is not a formality you add to every claim over the line: it is a statement that can be checked.
Documentation that holds up
CMS’s documentation guidance for outpatient therapy (MLN905365) centres on a few things that matter most above the threshold:
- A current, certified plan of care with goals, frequency and duration, signed by the physician or NPP within the required time.
- Progress reports at least every 10 treatment days showing objective change or why skilled care is still needed.
- Measurable goals and progress against them, not just a list of exercises.
- Why a therapist’s skills are needed what the patient couldn’t safely do with a home program or caregiver alone.
- Daily notes that match the billed units timed minutes per code and total timed minutes for the 8-minute rule.
Example of a weak note: “Pt tolerated tx well. Continue POC.” A stronger one: “Sit-to-stand improved from 3 to 6 reps without UE support; still requires min assist for stair descent due to quad lag. Skilled progression of eccentric loading and gait training needed to reach goal of independent community ambulation.”
Weak and strong notes: five examples
The difference between a claim that survives review and one that doesn’t is usually one paragraph. These examples are illustrative, not templates; write what is true for your patient.
| Patient | Weak | Stronger |
|---|---|---|
| Total knee replacement, week 7 | Pt doing well. Continue exercises per POC. | Knee flexion 98° (goal 110°) after plateau at 92° for 2 weeks; single-leg stance 4 s on operated side (goal 10 s) with persistent quad lag on stairs. Skilled manual therapy and progressive loading needed; home program alone has not progressed range in 14 days. |
| Chronic low back pain | Back pain 5/10. Continue therapy. | Oswestry improved 46% → 34% since recert; still unable to lift 10 lb from floor without pain flare (goal: lift 20 lb safely for job). Graded lifting progression and movement retraining require therapist cueing and load decisions each session. |
| Stroke, PT and speech | Gait improving. Speech ongoing. | Gait speed 0.48 → 0.62 m/s (community threshold 0.8); needs mod assist for curbs. Fall risk remains high (Berg 41/56). Skilled gait and balance training continues; speech plan tracked separately but shares the PT/SLP threshold. |
| Rotator cuff repair, post-op month 3 | Shoulder ROM better. | Active elevation 120° (goal 150°); external rotation strength 3+/5. Transition to resisted strengthening per surgeon protocol requires skilled progression and monitoring of repair integrity. |
| Parkinson’s disease, maintenance | Maintenance therapy. | Without skilled intervention, freezing episodes increased from 1 to 4 per day during last therapy gap. Therapist must design and adjust cueing strategies and train caregiver; a safe home program can’t be carried out without these skills. Goal: maintain independent household ambulation. |
What the stronger notes share: an objective measure, a gap to a functional goal, and a reason the work needs a therapist rather than a home program.
Six patient examples
Knee replacement rehab, one clinic. Evaluation then two visits a week. At national rates she reaches $2,480 on about visit 25. From that visit on, each claim line needs KX, and the record must show why continued skilled therapy is still necessary.
Two clinics in the same year. A patient had 14 PT visits at another clinic in spring and starts with you in October. The threshold counts allowed amounts from every provider in the calendar year, so he may already be near or over it. Check his year-to-date amount before the first visit.
PT and speech for the same patient. PT and speech share one $2,480 amount. A stroke patient seeing both disciplines reaches it much sooner than one seeing PT alone (see the table below), so both teams need to watch the same running total.
PT and OT for the same patient. OT has its own $2,480 amount. A patient can be over the PT/speech threshold and well under the OT one; each needs its own tracking.
Maintenance therapy. Skilled maintenance therapy can be covered when it requires a therapist’s skills, even without improvement. Over the threshold, the KX modifier and documentation must show why the skills of a therapist are needed.
New calendar year. Amounts reset on January 1. A patient over the threshold in December starts again from zero in January, though the medical necessity documentation should continue the same story.
Tracking it in practice
- At intake, check the patient’s year-to-date therapy amounts through your Medicare eligibility check, including other providers.
- Set an alert in your EHR or billing system about $400 before the threshold.
- At the alert, make sure the plan of care and latest progress report clearly support continued skilled care.
- From the threshold on, add KX to each claim line only when that is true.
- Near $3,000, review the chart as if an auditor were reading it.
Where KX goes on the claim
KX goes on each claim line for a service furnished after the threshold is reached, alongside the GP, GO or GN modifier that identifies the therapy discipline, and alongside CQ or CO when an assistant furnished the service. Lines without KX above the threshold are denied, so build the check into claim scrubbing rather than relying on memory.
Example. Visit 25 at national rates: 97110 × 2 with GP and KX, 97140 with GP and KX, 97530 with GP and KX. If the PTA furnished the 97110 units, those lines carry GP, CQ and KX.
Talking to patients about it
Patients often remember the old “cap” and worry their therapy will stop. A short explanation helps:
That last sentence matters: it sets up the ABN conversation honestly, before it is needed.
Year-end planning
Amounts reset on January 1. For a patient close to the threshold in November, there is no reason to rush or delay care for billing reasons; treat to the plan of care. But do make sure the December progress report is strong, because it is the record a reviewer reads if any late-year claims are selected, and it sets up the new year’s plan.
One patient, start to finish
A worked case (invented patient, real 2026 national rates). Mrs. A., 71, starts outpatient PT on March 3 after a total knee replacement. No other therapy this year.
- Day 1. Evaluation (97162) plus two units of 97110: $142.29 allowed. Plan of care: three times a week for 12 weeks. The front desk records the year-to-date total as $142.29.
- Weeks 1–4. Ten treatment visits at about $100.70 each bring her to roughly $1,149. Her first progress report, due by the tenth treatment day, shows flexion up from 75° to 95°.
- Week 7. After visit 21, the billing system flags that she is within $400 of $2,480 ($324 left). The therapist reviews the chart: goals updated, objective gains documented, stair negotiation still unsafe.
- Visit 25 (week 8). The running total passes $2,480. Every line on this claim and later ones carries KX, and each daily note ties the session to the remaining goals.
- Visit 30 (week 10). She passes $3,000. Nothing changes in the billing, but the clinic knows these claims could be selected for review and checks the last progress report reads well on its own.
- Discharge. Goals met; discharge summary documents final measures and the home program.
Nothing in this case required a special form or permission. What made it safe was tracking the total from day one and keeping the record ahead of the claims.
What a reviewer asks of a KX claim
- Is there a plan of care certified for the dates of service?
- Does the most recent progress report show objective status and why skilled care continues?
- Do the daily notes support the codes and units billed?
- Is it clear what the therapist did that a patient or caregiver couldn’t do alone?
- Are the goals functional and measurable, and is the patient moving toward them or being maintained for a documented reason?
- Do the modifiers match who furnished the service (GP/GO/GN, CQ/CO, KX)?
Who does what in a small practice
| Role | Job |
|---|---|
| Front desk | Pull year-to-date therapy amounts at intake; tell the therapist if the patient is already close. |
| Billing | Track allowed amounts per patient per threshold; alert $400 before; add KX only when the therapist confirms; scrub claims for missing KX. |
| Therapist | Keep the plan of care and progress reports current; confirm medical necessity before KX; raise an ABN conversation when coverage is doubtful. |
| Owner | Audit five KX claims a quarter against the reviewer checklist above. |
What changes in 2028
The KX threshold already rises each year with the Medicare Economic Index. The $3,000 medical review threshold is fixed until 2028, when CMS says it will also start being indexed annually by the MEI (CMS). Check both amounts every January; we update this guide and the KX check when CMS publishes them.
Above $3,000: targeted review
Until 2028 the review threshold stays at $3,000, after which it will be indexed by the MEI. CMS notes that not all claims above it are reviewed as they once were; review is targeted (CMS). The best preparation is the same as for KX: a chart that tells a clear story of need, progress and plan.
ABNs and liability
The 2018 law didn’t change the limitation of liability rules that protect patients when services are denied for certain reasons, including a missing KX modifier, and CMS points providers to its August 2018 ABN FAQs (CMS). In practice: if you believe Medicare may not pay because a service may not be medically necessary, follow the ABN guidance before providing it. KX is for services you believe are necessary; an ABN is for ones you think Medicare may not cover.
Common mistakes
- Not checking other providers’ amounts at intake.
- Tracking charges instead of allowed amounts.
- Tracking OT and PT together, or PT and speech separately.
- Adding KX automatically without reviewing the chart.
- Forgetting KX and getting denials.
- Letting progress reports lapse just when they matter most.
Glossary
- Allowed amount: what Medicare recognizes for a service under the fee schedule, split 80% Medicare and 20% patient after the deductible.
- KX modifier: a claim modifier confirming services above the threshold are medically necessary and supported by the record.
- GP, GO, GN: modifiers identifying physical therapy, occupational therapy and speech-language pathology services.
- CQ, CO: modifiers for services furnished in whole or in part by a PTA or OTA, paid at 85%.
- MEI: the Medicare Economic Index, which CMS uses to raise the KX threshold each year.
- Targeted medical review: review of selected claims above the review threshold, chosen rather than automatic.
- ABN: Advance Beneficiary Notice of Non-coverage, given before a service Medicare may not pay for.
Questions
What is the KX threshold for 2026?
$2,480 for PT and speech-language pathology combined, and $2,480 for OT, per patient per calendar year.
Is there still a therapy cap?
No. Section 50202 of the Bipartisan Budget Act of 2018 repealed the caps and their exceptions process. The old cap amounts remain as thresholds above which the KX modifier is required.
What happens if I forget KX above the threshold?
CMS says claims over the threshold without the KX modifier are denied.
Does every claim over $3,000 get reviewed?
No. CMS says not all claims above the $3,000 medical review threshold are reviewed as they once were; review is targeted.
Do the amounts include other providers’ services?
Yes. The threshold applies per patient across all providers in the calendar year, which is why you should check year-to-date amounts at the start of care.
Do I need an ABN?
CMS says the 2018 law did not change the liability protections for patients, and refers providers to its August 2018 ABN FAQs. Use an ABN when you expect Medicare may not pay because a service may not be medically necessary, following those FAQs; KX is not a substitute for that judgement.
Does KX change how much Medicare pays?
No. KX doesn’t raise or lower the payment for a service; it is what allows a service above the threshold to be paid at all.
Can I add KX before the threshold, just in case?
KX belongs on services above the threshold. Adding it early doesn’t protect a claim, and it confuses tracking and audits.
How do I find a new patient’s amount from other providers?
Medicare eligibility responses show the patient’s therapy amounts applied so far in the year. Check at intake and again if the patient mentions therapy elsewhere.
Does this apply to Medicare Advantage?
The KX threshold is a traditional Medicare Part B rule. Medicare Advantage plans set their own authorization and visit rules.
Sources
- CMS, CY 2026 Therapy Services Updates (MPPR, CQ/CO, KX threshold) — the 2026 KX and review thresholds, KX meaning, denials without KX, targeted review and liability protections
- APTA, Medicare therapy threshold — background on the threshold and its history
- CMS MLN905365, Complying with Outpatient Rehabilitation Therapy Documentation Requirements — documentation requirements for outpatient therapy
- CMS Medicare Claims Processing Manual, chapter 5, section 20.2 — therapy billing rules
- CMS, PFS Relative Value Files: RVU26D (released August 26, 2026) — visit amounts used to estimate when patients reach the thresholds
- HHS OIG, A-05-14-00041 (March 2018) — the 2018 audit of outpatient PT claims
General information as of October 26, 2026, not billing or legal advice. Visit counts are estimates from CMS 2026 rates for the example visit described; your patients’ amounts depend on their codes, your locality and other providers’ services.