Physical therapists and PT practices have a well-established Medicare enrollment pathway. But enrollment is just the beginning — once you’re enrolled, PT billing requires understanding therapy caps, the KX modifier, and annual threshold changes that affect every PT billing under Medicare.
This guide covers enrollment and the key billing rules PTs need to know.
PT Medicare enrollment: the basics
Physical therapists in independent practice enroll in Medicare as individual providers via the CMS-855I. PT practices (group or organizational) enroll via the CMS-855B and coordinate individual PTAs and assistants through CMS-855R reassignments.
Your Medicare enrollment category:
- Physical Therapist in Independent Practice (PTIP) — taxonomy code: 225100000X
- Physical Therapy Group Practice — taxonomy code: 225100000X (organization level)
PT assistants (PTAs): Medicare requires PTAs to be enrolled separately. PTAs bill under the supervision of an enrolled PT, with a CQ modifier on claims to indicate PTA services (and the associated 85% payment rate under Medicare for PTA-delivered services, effective 2020).
Key applications for physical therapists
| Form | Purpose |
|---|---|
| CMS-855I | Individual PT enrollment |
| CMS-855B | PT practice/organization enrollment |
| CMS-855R | Reassignment (PT to practice) |
| CMS-460 | Participating provider agreement |
| CMS-588 | EFT setup |
Step-by-step: Individual PT enrollment
Step 1: Confirm your NPI and taxonomy Your Type 1 NPI must be active with taxonomy 225100000X (Physical Therapist). NPPES guide →
Step 2: Confirm your state PT license is current Medicare will verify your license with your state licensing board. Enrollment with an expired or lapsed license is denied.
Step 3: Create a PECOS account PECOS account guide →
Step 4: File CMS-855I in PECOS Individual enrollment for the physical therapist. CMS-855I guide →
Step 5: File CMS-460 (recommended) Most PTs should sign the Medicare participating provider agreement.
Step 6: File CMS-588 for EFT Paper form to your MAC.
Step 7: If employed by a practice, file CMS-855R After individual enrollment is approved, reassign benefits to your employing practice.
CY2026 therapy threshold: what PTs must know
Medicare imposes an annual dollar threshold on outpatient physical therapy services (combined with speech-language pathology services). For CY2026:
Combined PT + SLP threshold: $2,480 Occupational therapy separate threshold: $2,480
How the threshold works:
- Services below the threshold: billed normally
- Services above the threshold: require the KX modifier on each claim, certifying that the services are medically necessary and meet Medicare coverage criteria
- Services above the soft cap (currently $3,700 for PT+SLP): may trigger Medicare review; KX modifier still required; detailed documentation essential
The KX modifier: Adding the KX modifier to claims above the threshold certifies that the services provided are medically necessary and that documentation in the medical record meets Medicare coverage criteria. This is the therapist’s attestation — claims with KX modifiers can trigger ADR (additional documentation requests) and audit.
⚠️ Don’t add the KX modifier to justify services that don’t meet medical necessity standards. The KX modifier represents a clinical certification. Routine attachment without supporting documentation is a compliance risk.
PTA billing under Medicare (85% rule)
Services provided by a Physical Therapist Assistant (PTA) are reimbursed at 85% of the Medicare fee schedule rate when:
- The PTA provides all or part of the service
- The CQ modifier is applied to the claim
A claim where a PTA provides the full service carries the CQ modifier and is paid at 85%. Claims where both the PT and PTA provide portions of the service require the CQ modifier on the lines for PTA-delivered service.
⚠️ PTA supervision requirement: Medicare requires the supervising PT to be on the premises (in the suite) during PTA service delivery. “General supervision” (PT available by phone) is not sufficient for outpatient PT. Verify your supervision arrangement meets Medicare standards.
⚠️ Risk flags
⚠️ Functional outcome reporting. Medicare requires completion of standardized functional assessment tools at specific intervals (initial, every 10 visits, at discharge). Missing functional reporting is a compliance deficiency that shows up in audits.
⚠️ Medical necessity documentation. PT claims above the threshold are audit targets. Documentation must support: the specific diagnosis, the specific interventions, the functional goals, the clinical rationale for ongoing treatment, and progress toward goals.
⚠️ Manual therapy complexity. Certain manual therapy codes (97140) have documentation requirements that go beyond standard SOAP note format. Verify your documentation captures the elements CMS requires for these codes.
MCO enrollment for PTs
Medicare Advantage plans often have separate prior authorization requirements for physical therapy, including:
- Prior auth for initial PT evaluation
- Prior auth or authorization for ongoing visits beyond an initial approval
- Episode-of-care authorizations with visit caps
When joining MCO networks: MCO enrollment guide →
Resources
- KX Threshold CY2026 Update
- CMS-855I — Individual Enrollment Guide
- PECOS Overview
- Organizations — Group Practice Enrollment
- Free Medicare Enrollment Audit
PT Medicare enrollment questions? Ask Mae → Free enrollment audit from Metolius Health →