Occupational therapists enroll in Medicare as individual providers in independent practice or as part of an OT organization. The enrollment pathway is similar to physical therapy, with a parallel therapy threshold structure and OTA billing rules that mirror the PTA rules.
OT Medicare enrollment overview
Individual OT taxonomy code: 225X00000X OT practice/organization: Enrolled via CMS-855B
Occupational therapists in independent practice file the CMS-855I. OT practices enroll via CMS-855B with each OT filing CMS-855I individually and reassigning via CMS-855R.
Key applications for OT providers
| Form | Purpose |
|---|---|
| CMS-855I | Individual OT enrollment |
| CMS-855B | OT practice enrollment |
| CMS-855R | Reassignment to practice |
| CMS-460 | Participating provider agreement |
| CMS-588 | EFT setup |
Step-by-step: Individual OT enrollment
Step 1: Verify NPI and taxonomy Active Type 1 NPI with taxonomy 225X00000X. Verify in NPPES before filing.
Step 2: Confirm state OT license is current Medicare verifies with the state licensing board.
Step 3: Set up PECOS account PECOS account setup →
Step 4: File CMS-855I in PECOS CMS-855I guide →
Step 5: File CMS-460 (participating agreement) Step 6: File CMS-588 (EFT authorization) Step 7: File CMS-855R (if employed by practice)
CY2026 OT therapy threshold
Occupational therapy has its own separate annual threshold from the PT+SLP combined threshold:
OT threshold for CY2026: $2,480 (separate from the PT+SLP $2,480 threshold)
This means a patient could receive both OT and PT+SLP services up to $2,480 each before the KX modifier kicks in — distinct therapy limits.
Full KX threshold guide for CY2026 →
KX modifier for OT: Same rules as PT — services above the threshold require the KX modifier, certifying medical necessity. Documentation must support the KX modifier attestation.
OTA billing under Medicare (85% rule)
The 85% payment rule applies to Occupational Therapy Assistants (OTAs) under Medicare, effective 2022:
- Services provided by an OTA require the CO modifier
- Claims with CO modifier are paid at 85% of the Medicare fee schedule
- The supervising OT must be on the premises during OTA service delivery (general supervision not sufficient for most outpatient OT services)
OTA enrollment: OTAs must be enrolled in Medicare to provide services that will be billed to Medicare. OTAs file CMS-855I with the OTA taxonomy code (225XA0019X).
OT scope of practice and Medicare coverage
Medicare covers OT services that are medically necessary for the treatment of illness, injury, or the restoration of function. Common covered OT services:
- Activities of daily living (ADL) training
- Cognitive rehabilitation
- Upper extremity rehabilitation following stroke, injury, or surgery
- Fine motor skill development in medically necessary contexts
- Adaptive equipment assessment and training
- Work hardening / functional capacity evaluation (specific coverage rules apply)
Not covered by Medicare: Maintenance therapy (when the goal is maintaining current function rather than improving function) is not covered. Documentation must reflect improvement toward functional goals.
⚠️ Risk flags
⚠️ Maintenance therapy documentation. If a patient reaches a plateau in progress, continued therapy for maintenance is generally not a Medicare-covered service. OTs must document that services are directed toward improvement, not just maintenance, or that there is a period of decline being addressed.
⚠️ ADL vs. skilled service distinction. Not all ADL assistance is a skilled OT service. Medicare covers OT that requires the skills of an OT — services that could be performed by a non-skilled caregiver are not covered. Documentation must reflect the skilled nature of the service.
⚠️ CO modifier requirements. If an OTA provides any portion of a service, the CO modifier must be applied. Missing CO modifiers on OTA-provided services creates compliance exposure.
MCO considerations for OT
Medicare Advantage plans commonly require prior authorization for OT services. Manage PA workflow before joining MCO networks. MCO enrollment guide →
Resources
- KX Threshold CY2026 Update
- CMS-855I — Individual Enrollment Guide
- Group Practice Medicare Enrollment
- Free Medicare Enrollment Audit
OT Medicare enrollment questions? Ask Mae →