Specialties / Physical therapy
Physical therapy billing, done for you
Your therapists document the care. We code every visit from their notes: timed units under the 8-minute rule, GP, KX, CQ and plan-of-care dates. We check every claim against Medicare's and your payers' rules before it goes out, then post payments, work unpaid claims and bill your patients. You keep your EMR and see every claim live.
Live for physical therapy practices.
Charge review
Claim C-28941
Secondary plan| Code | Service | Modifiers | Minutes | Units | Charge | Allowed | Expected |
|---|---|---|---|---|---|---|---|
| 97140 | Manual therapy | GP CQ | 30 | 2 | $156.00 | $36.58 | $36.00 |
| 97530 | Therapeutic activities | GP CQ | 15 | 1 | $90.00 | $28.82 | $28.35 |
| 97112 | Neuromuscular re-education | GP CQ | 17 | 1 | $85.00 | $22.71 | $22.35 |
| Total | 62 | 4 | $331.00 | $88.11 | $86.70 |
Expected is the allowed amount less Medicare sequestration (2% of Medicare's payment, CARC 253).
Checks before the claim went out
7 of 7 passed- Passed: 62 timed minutes = 4 units under Medicare's 8-minute rule (53 to 67 minutes).Software
- Passed: GP on every line.Software
- Passed: CQ on every line: a PTA furnished the visit. Medicare pays these lines at 85%.Software
- Passed: KX not needed: $1,298.63 of therapy this year before this visit, under $2,480.Software
- Passed: Plan of care certified Jul 15 through Sep 23; this visit is covered.Software
- Passed: 97140 with 97530 on the same day: no Medicare code-pair edit since 2020, so no 59 or X modifier.Software
- Passed: Units within Medicare's daily limits (MUE).Software
What we do for your clinic
The full scope, line by line- Coding and charge reviewIncluded
- Claim scrubbing and submissionIncluded
- Payment postingIncluded
- Denials and appealsIncluded
- Accounts receivable (A/R) follow-upIncluded
- Patient statements and callsIncluded
- Live dashboard and monthly summaryIncluded
- Eligibility and benefitsAutomated check only
- Prior authorizationTracking only
- Credentialing and payer enrollmentNot included
- For physical therapy, we code timed units, GP, KX and CQ from your therapists' notes and check plan-of-care dates on every claim.
- Plan-of-care and recertification dates are tracked with authorizations. Your front desk submits prior authorization requests; we track visits used against visits approved.
What makes PT billing different
The rules we code and check before a PT claim goes out
We check code pairs and daily unit limits against Medicare's current quarterly files.
| Rule | What it means | What we check | Who decides | Sources |
|---|---|---|---|---|
| Timed units | Medicare: total timed minutes to units (8 to 22 = 1, 23 to 37 = 2, 38 to 52 = 3, 53 to 67 = 4). A code done 15 minutes or more gets at least 1 unit. Some commercial plans use the CPT per-code rule. | Units match the documented minutes under each payer's written method | Mohenara codes units from your therapist's documented minutes | 1,2 |
| Minutes on the note | Each treatment note shows the services, total timed minutes, total treatment minutes and a signature. | Minutes present; note signed before the claim goes out | Your therapist documents and signs; Mohenara checks before sending | 8 |
| GP modifier | Required on every line under a PT plan of care, evaluations included. Without it the claim is returned (CO-4). | GP on every line | Mohenara codes GP on every line from your documentation | 1 |
| KX threshold | $2,480 for physical and speech therapy combined, counting other clinics this year; Medicare's eligibility response reports that use. Lines above it without KX are denied and the clinic cannot bill the patient. Targeted review can apply above $3,000. | Each Medicare patient's running total against $2,480, from the claims we bill; KX goes on only when the documentation supports medical necessity | Mohenara adds KX when your therapist's documentation shows the care is medically necessary | 4,5,6,11 |
| CQ for PTA services | A PTA furnished more than 10% of a service on their own: CQ next to GP; Medicare pays 85%, with two narrow exceptions. | CQ where the note shows it, always with GP; the 85% payment posted as expected | Mohenara codes CQ from who furnished the care in your documentation | 3,1,12 |
| Plan of care certification | Signed by a physician, NP, PA or CNS within 30 days of the first visit, or since 2025 an order or referral on file plus a documented send of the plan within 30 days. Up to 90 days per certification; recertify when it ends or changes significantly. The certifier's NPI goes on the claim. | Date of service inside a certified period; referring NPI present; a warning before the plan lapses | Your therapist documents and signs the plan of care; your clinic gets it certified; Mohenara tracks the dates | 7,8 |
| Progress reports | At least once every 10 treatment days, written by the PT, not a PTA. A missed one is due within 7 days after the period ends. | Rule only | Your therapist writes and signs them; Mohenara tracks when they are due | 8 |
| Code pairs | Some pairs pay only when done in separate time blocks with 59 or XU (97150 with 97110). Some never pay together (97140 with 97124). Medicare has had no edit between 97140 and 97530 since 2020. | Pairs against the current quarter's edit file; 59 or XU only when the note shows separate time | Mohenara codes from your documentation | 13,14 |
| Units per day | 97110, 97140 and 97530: 6 units; 97112 and 97116: 4; evaluations, re-evaluations and 97150: 1 (effective 2026-10-01). | Units within the daily limit | Mohenara codes units from your documentation | 15 |
| Codes Medicare does not pay | 97014 is not valid for Medicare (bill G0283); hot and cold packs (97010) are bundled. | For Medicare, G0283 in place of 97014, and bundled codes such as 97010 left off, before the claim goes out | Mohenara codes from your documentation | 15,16 |
| Evaluations | One evaluation or re-evaluation per day. A re-evaluation (97164) is not routine: new findings, a significant change or no response to treatment. | A re-evaluation goes out only with a documented reason | Mohenara codes from your documentation; your therapist documents the reason for a re-evaluation | 14,8 |
| ABN and KX | Never KX and GA on the same line. The patient can be billed for care that is not medically necessary only with a valid ABN signed before the visit. | GA only with an ABN on file; never KX with GA | Your front desk gets the ABN signed; Mohenara adds GA only with it on file | 11 |
| Authorizations and visit limits | Some Medicare Advantage and commercial plans require authorization or cap visits (UnitedHealthcare Medicare Advantage since 2024-09-01). Since 2026, Medicare Advantage plans must answer standard requests within 7 calendar days. | Authorization number on the claim; visit inside the approved count and dates | Your front desk requests authorizations; Mohenara tracks visits and dates | 10,17 |
| Timely filing | Medicare: one calendar year from the date of service. Other payers set their own. | Each payer's deadline tracked; aging claims worked before it | Mohenara | 18 |
| Multiple procedure reduction | The practice expense part of the second and later units the same day is paid at 50%; the remittance shows CO-59. | Posted as expected, not as an underpayment | Mohenara | 4,1 |
Medicare changes code-pair and unit edits each quarter and the KX amount and fees each January.13,4,5
Before the visit
Software
Automated check
- Coverage active, plan dates, copay, coinsurance, deductible and therapy benefits, as the insurance company returns them.
- An answer the payer leaves incomplete stays unknown, never zero.
Software
Tracking
- Visits used against visits approved, and authorization end dates.
- Plan-of-care certification and recertification dates.
You
Your front desk
- Fixes insurance cards and details in your EMR.
- Requests authorizations.
- Gets Advance Beneficiary Notices (ABNs) signed when needed.
- Collects copays.
A coverage check is not a guarantee of payment.
Who does what
You
Your therapists
- Document the care, with timed and total minutes, and sign each note.
- Write and sign the plan of care.
- Write progress reports at least every 10 treatment days.8
- Document medical necessity for care above the KX amount.
- Answer our documentation questions.
You
Your front desk
- Insurance cards and details.
- Authorization requests.
- Scheduling inside approved visits.
- ABN signatures.
- Copays at the visit.
You
You
- Set the financial policy.
- Approve refunds, and write-offs above a limit you set.
- Keep credentialing and payer enrollment current.
- See every claim live in your dashboard.
Mohenara
Mohenara
- Codes every visit from your therapists' documentation: units under each payer's method, GP, KX and CQ.
- Checks every code and unit against the note and the payer's rules before the claim goes out. We never upcode.
- Sends claims, posts payments, works denials, appeals and unpaid claims, sends patient statements and answers patients' billing calls.
- Keeps your dashboard current and sends your monthly summary.
Why PT claims get denied or paid back
The public evidence comes from two places: Medicare audits of claims it already paid, and claim rules that deny automatically. Each cause below shows its source.
| Cause | What happens | Evidence |
|---|---|---|
| Missing or late plan-of-care certification | Medicare recovers the payment in audits | In CERT 2025, the top root causes in the Part B category that includes therapy were certification or recertification missing (62 audited claims), reason for a late certification missing (28), plan of care missing (20) or inadequate (11). Medicare audit data, not a denial rate.19 |
| Documentation does not support the claim | Payment recovered | PTs in private practice: 19.9% improper payment rate; 88.3% of it insufficient documentation (claims from 2023-07-01 to 2024-06-30). Medicare audit data, not a denial rate.19 |
| No GP on a therapy code | Claim returned (CO-4) | Medicare Claims Processing Manual, chapter 5.1 |
| No KX above the threshold | Line denied with claim adjustment reason code (CARC) 119; the clinic cannot bill the patient | CMS therapy services guidance, its ABN and therapy FAQ, and the Medicare Claims Processing Manual, chapter 5.4,11,1 |
| CQ without GP | Returned as unprocessable | Medicare Claims Processing Manual, chapter 5.1 |
| Code pair without a valid 59 or XU, or a pair that never pays together | Second code denied | Medicare's quarterly code-pair edit file.13 |
| Units over the daily limit | Extra units denied | Medicare's quarterly daily unit limit file.15 |
| Patient in an open Medicare home health period | Outpatient therapy claim rejected | Medicare Claims Processing Manual, chapter 10.20 |
| Authorization missing, or visits beyond it | Denied (CARC 197 or 198) | UnitedHealthcare's Medicare Advantage therapy authorization policy, and the standard reason code list.10,21 |
| Plan visit limit reached | Denied (CARC 119) | The standard reason code list.21 |
| Another payer primary, coverage ended, duplicate, filed late | CARC 22, 27, 18, 29 | The standard reason code list, and Medicare's one-year filing limit.21,18 |
Where each patient stands
Plan of care, authorization and Medicare therapy dollars on one row per patient, live in your dashboard.
Patients
Showing 6 of 56 active patients (seen in the last 10 days or with a visit scheduled). 26 new evaluations Sep 1 to 28.
| Patient | Payer | Therapist | Visits billed | Next visit | Plan of care / authorization / threshold | With payers | Patient owes | Where it stands |
|---|---|---|---|---|---|---|---|---|
| Pt 2137 | Medicare Part B + supplement | PT 2 with PTA 1 (North) | 16 (since Jul 15) | None (discharged) | Certified through Sep 23; $1,479.14 of $2,480 | $118.32 | $0.00 | 2 claims waiting on the supplement plan, 1 with Medicare. |
| Pt 2150 | Medicare Part B + supplement | PT 1 (North) | 14 (since Jul 21) | Sep 30 | Certified through Sep 24 (expired); $1,425.44 of $2,480 | $527.01 | $0.00 | Recert not signed: Sep 28 visit held. 2 older claims denied, being corrected. |
| Pt 2166 | Medicare Part B + supplement | PT 3 (South) | 19 (since Jul 30) | Oct 1 | Certified through Oct 28; $3,329.84 this year: KX since Aug 26, above $3,000 | $529.38 | $0.00 | Paid normally with KX. Therapist reminded to document skilled need. |
| Pt 2220 | Medicare Part B + supplement | PT 1 (North) | 11 (since Aug 20) | Oct 5 | Certified through Oct 18; $1,073.80 of $2,480 | $486.07 | $283.00 | Sep 23 note: minutes do not match units (held). Owes the $283 Part B deductible. |
| Pt 2180 | Medicare Part B + supplement | PT 4 (South) | 13 (since Aug 7) | Oct 6 | Certified through Oct 2; $1,131.96 of $2,480 | $219.36 | $0.00 | Recert needed before the Oct 6 visit. |
| Pt 2294 | Commercial HMO C | PT 4 (South) | 2 (since Sep 25) | Oct 2 | 2 of 8 visits authorized; 9 scheduled | $190.92 | $0.00 | $20 copays collected at visits. Request more visits before Oct 19. |
"Visits billed" counts this episode's claims to date. "With payers" is open on this patient's claims that insurers or the supplement plan still owe, including held visits, net of Medicare sequestration. "Patient owes" is open after the payer decided. "This year" is Medicare-allowed therapy dollars from Jan 1 on the claims we bill.
Insurance types
| Insurance type | What we bill |
|---|---|
| Original Medicare | Included |
| Medicare Advantage | Included. Authorizations tracked; your front desk requests them. |
| Commercial plans | Included. We follow each plan's written unit-counting rule. |
Orthopedic, sports, pelvic health, vestibular, neurologic, aquatic
Therapy billed under a physical therapy plan of care uses the same codes and rules, whatever the focus of your clinic.
Nine questions to ask any PT biller
How do you count timed units for each of my payers, and where is that written down?
Each payer's written rule: Medicare's total-minutes method, or the per-code rule where a plan says so.
How do you track the KX amount, including therapy my patients had elsewhere this year?
A running total per Medicare patient against $2,480,4 from the claims we bill. Medicare's eligibility response also reports dollars used at other clinics.6
Who puts KX on the claim, and what do you need from my therapists first?
We do, when your therapist's documentation shows the care is medically necessary.
How will you warn us before a plan of care or an authorization runs out?
They are tracked with dates and go on your front desk's list before they end.
Who codes our visits, and what happens when a note is unclear?
We code from the signed note and bill only what it supports. When it does not support the units, we ask your therapist to clarify. We never upcode.
Which code-pair edits do you check?
Medicare's current quarterly code-pair and unit files.
How do you post the multiple procedure reduction and PTA payments?
As expected amounts, not as underpayments.
Do you do credentialing or prior authorization requests? If not, who does?
Credentialing stays with your practice or a credentialing service. Your front desk requests authorizations, and we track visits used against visits approved.
What will I see, and when? Can I see denials by payer and reason?
Everything, live: every claim, what is owed and how old it is, and denials by payer and reason. Plus a monthly summary.
Physical therapy questions
We track each Medicare patient's therapy dollars against $2,480 (2026, physical and speech therapy combined), from the claims we bill.4 KX confirms the care is medically necessary and documented. We add it when your therapist's documentation shows that, and ask your therapist when it does not.
Without KX, lines above the amount are denied and you cannot bill the patient for them.11
Yes. We track plan-of-care certification and recertification dates, including the 2025 order-or-referral route, and warn your front desk before they end.7
Yes. CQ goes on with GP when a PTA furnished more than 10% of a service on their own, and Medicare pays those lines at 85%.3
We post Medicare's multiple procedure reduction and the 85% payment on PTA lines as expected amounts, not as underpayments.
Yes. We bill them and track their authorizations. Your front desk still requests authorizations.
Your front desk has the patient sign the ABN before the visit.
We check that a claim carries GA only when an ABN is on file, and never KX and GA on the same line.11
In 2026 the Part B deductible is $283; after it, the patient pays 20% of the Medicare-approved amount.25
We bill the patient's share after Medicare pays, and our billing specialists answer your patients' billing questions under your financial policy.
Get a billing plan for your clinic
A written plan with the billing we run for you, your price at 3.5% of what we collect, and what that comes to on your numbers.