For outpatient orthopedic, sports, neuro and vestibular, pelvic health and multi-location PT clinics billing Medicare, commercial plans, auto and workers compensation.
At 2026 national Medicare rates, a PT visit with two units of therapeutic exercise and one unit of manual therapy pays $72.48 after the multiple procedure payment reduction. That margin disappears one unit at a time: minutes counted code by code, PTA minutes billed without CQ, an auto claim filed late. In our billing reviews, 33% of therapy episodes had a coverage change mid-episode that was not caught. Our full-service medical billing team fixes those inside your PT EHR before claims go out.
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Physical therapy billing services turn PT visit notes into paid claims: checking benefits and visit limits, converting treatment minutes to units, applying GP, CQ and KX modifiers, tracking plans of care, and working denials and AR. In a Luxen claim audit, the KX modifier was missing on 21% of Medicare therapy claims past the threshold.
PT billing changes with the setting and with who pays for the injury.
Service lines we bill: evaluations and re-evaluations, timed and group treatment, remote therapeutic monitoring, telehealth, auto PIP and workers compensation.
PT revenue leaks on rules that apply to every visit. Medicare figures use 2026 national RVUs at the $33.4009 conversion factor, non-facility, before geographic adjustment and patient cost sharing.
| Scenario | Codes | What goes wrong | $ at stake per claim | Luxen audit finding |
|---|---|---|---|---|
| Several timed codes in one visit | 97110, 97112, 97140 | Units counted per code, not from total timed minutes | $29.06 per unit of 97110 | 8-minute rule unit errors appeared on 9% of therapy claims |
| Medicare visit after PT and speech spending passes $2,480 | GP, KX | Line denies without KX despite medical necessity | $72.48 for a 3-unit visit after MPPR | The KX modifier was missing on 21% of Medicare therapy claims past the threshold |
| Plan of care not certified within 30 days | 97161 to 97163 and every visit under the plan | Visits under the plan are exposed on review | $97.86 per evaluation, plus each visit | Plan of care certification was unsigned past 30 days on 7% of Medicare episodes |
| PTA furnishes part of the service | CQ | Paid at 100% instead of 85%, creating an overpayment | $13.08 on 3 units of 97110 before MPPR | Coding and modifier errors caused 21% of denials |
| Coverage changes during the episode | All PT codes | Visits bill to a plan that ended or hit its visit limit | $72.48 per 3-unit visit | 33% of therapy episodes had a coverage change mid-episode that was not caught |
| Florida auto claim billed late | Any PT code billed to PIP | Charges sent after the 35-day PIP window | The full visit charge, against a $10,000 PIP benefit | Timely filing caused 6% of denials, and only 4% of those were recovered |
Most PT claims draw on about a dozen codes, and a few familiar ones are not payable by Medicare at all. Amounts below use CMS 2026 national RVUs at the $33.4009 conversion factor, non-facility, before geographic adjustment. Certified coders on our medical coding team check each line against the note before submission.
| Code | Service | Billing unit | 2026 national amount |
|---|---|---|---|
| 97161 | PT evaluation, low complexity | 1 unit, untimed | $97.86 |
| 97162 | PT evaluation, moderate complexity | 1 unit, untimed | $97.86 |
| 97163 | PT evaluation, high complexity | 1 unit, untimed | $97.86 |
| 97164 | Re-evaluation of an established plan of care | 1 unit, untimed | $67.47 |
The three evaluation levels pay the same in 2026, so complexity selection matters for audit support, not payment. A re-evaluation belongs where the patient's status has changed, not on a calendar.
| Code | Service | Unit | 2026 national amount |
|---|---|---|---|
| 97110 | Therapeutic exercise | Each 15 minutes | $29.06 |
| 97112 | Neuromuscular re-education | Each 15 minutes | $32.73 |
| 97116 | Gait training | Each 15 minutes | $29.06 |
| 97140 | Manual therapy, one or more regions | Each 15 minutes | $27.72 |
| 97530 | Therapeutic activities | Each 15 minutes | $35.07 |
| 97150 | Group therapeutic procedures | Untimed, 1 unit per patient | $18.04 |
| G0283 | Unattended electrical stimulation, other than wound care | Untimed | $12.69 |
Every line under a PT plan of care carries GP. NCCI does not allow two one-on-one therapy services to be reported for the same 15 minutes, and modifier 59 or XU bypasses a therapy code pair edit only when the services were performed in different timed intervals.
Three rules decide what a Medicare PT visit pays: how minutes become units, who furnished them, and the practice expense reduction.
Medicare adds all direct minutes for 15-minute timed codes on the date of service, then converts the total: 8 to 22 minutes is 1 unit, 23 to 37 is 2, 38 to 52 is 3 and 53 to 67 is 4 (Medicare Claims Processing Manual, Chapter 5, section 20.2). When a unit is left to assign, it goes to the service with the most remaining minutes.
A PT spends 10 minutes each on therapeutic exercise (97110), manual therapy (97140) and neuromuscular re-education (97112). Counting per code bills 3 units, but 30 total minutes supports 2, so any two of the equal-minute codes take one unit each. The third unit, worth $27.72 to $32.73, is an overpayment.
Services furnished in whole or in part by a physical therapist assistant carry the CQ modifier and are paid at 85% of the fee schedule amount for dates of service since January 1, 2022 (42 CFR 410.60). CQ does not apply when the PTA furnishes 10% or less of the service. In a CMS example, a PTA provides 10 minutes of 97110 and the PT provides 5: the visit bills 1 unit of 97110 with CQ, which pays $24.70 instead of $29.06. Since January 1, 2025, PTAs working for a PT in private practice need general, not direct, supervision.
Medicare pays the service with the highest practice expense RVU in full and pays 50% of practice expense on every other therapy unit that day. On a moderate complexity evaluation with one unit each of 97110 and 97140:
| Line | Without MPPR | With MPPR |
|---|---|---|
| 97162 evaluation | $97.86 | $97.86 |
| 97110, 1 unit | $29.06 | $22.21 |
| 97140, 1 unit | $27.72 | $21.21 |
| Total | $154.64 | $141.28 |
A remit $13.36 below the unreduced total is correct payment, not an underpayment.
PT clinics bill more payer types than most specialties, each with its own rules.
All 50 states and DC allow some form of direct access to physical therapy, but a Medicare claim still needs a certified plan of care.
Many plans authorize PT in blocks of visits, and in our claim audit missing or invalid prior authorization caused 17% of denials. State law can remove the step: for practices billing in Indiana, a utilization review entity may not require prior authorization for the first 12 PT or chiropractic visits of a new episode of care, though Medicaid and the state employee plan are excluded. Our eligibility and prior authorization team checks each plan's rule before the first visit.
For clinics billing in Florida, the patient must receive initial care within 14 days of the accident, the benefit is $10,000, or $2,500 without an emergency medical condition, and insurers can limit payment to 80% of a schedule set at 200% of Medicare Part B. The statement of charges is due within 35 days of service, or 75 days when the provider sent notice of treatment within 21 days of the first visit.
Work injury visits bill to the employer's carrier under a state fee schedule, with their own claim number, reports and filing clock. We keep them off the patient's health plan so they are not denied as work related and left to age.
Direct access lets a patient start PT without a referral, but Medicare payment still requires the physician or NPP to certify the plan of care within 30 days and recertify at least every 90 days (CMS MLN905365). Every visit under an uncertified plan is exposed, starting with the $97.86 evaluation. Plan of care certification was unsigned past 30 days on 7% of Medicare episodes.
Medicare converts total timed minutes, so 10 minutes each of three codes is 30 minutes and 2 units, not 3 (Medicare Claims Processing Manual, Chapter 5). The extra unit is a $27.72 or larger overpayment. 8-minute rule unit errors appeared on 9% of therapy claims.
The threshold counts the patient's therapy spending for the calendar year, and PT and speech-language pathology share one $2,480 amount in 2026 (CMS Therapy Services). Without KX a line past it denies, $72.48 on a 3-unit visit. The KX modifier was missing on 21% of Medicare therapy claims past the threshold.
Medicare does not recognize 97014 and uses G0283 instead, paid at $12.69 nationally in 2026 (CMS Medicare Coverage Database, Article A56566). Coding and modifier errors caused 21% of denials in our claim audit.
For practices billing in Minnesota, health plan claims are due within six months of the date of service (Minnesota Statutes section 62Q.75). Medicare allows 1 calendar year (42 CFR 424.44). A late claim loses the whole visit: timely filing caused 6% of denials in our audit, and only 4% of those were recovered.
When these errors have already produced denials, our denials and AR recovery team works the oldest recoverable money first. We recovered 61% of the dollar value of claims aged 90 to 180 days that practices had stopped working.
We run the revenue cycle from eligibility to zero balance inside the practice management system you already use. How full-service billing works.
Certified coders review charges against your documentation and payer rules before the claim goes out, so the denial is prevented rather than appealed. Medical coding.
Aged and denied claims are worked to resolution, then the upstream cause is fixed so the same claims stop coming back. Denials and AR recovery.
Benefits are verified and authorizations secured before the appointment, which is the cheapest place in the cycle to stop a denial. Eligibility and prior authorization.
Statements, balance questions and payment plans are handled by the same team that worked the claim. Patient billing.
Payer enrollment and re-credentialing are tracked through to approval, so a lapsed credential never quietly stops payment. Credentialing.
A HIPAA-trained front-office assistant working inside your EHR on calls, scheduling, intake and referrals, alongside the billing team. Medical virtual assistant.
PT clinics record minutes, units and plan of care dates in therapy EHRs, so billing has to read the note where it lives. We work inside the systems you already run: WebPT, Raintree, Prompt, Net Health Therapy, TheraOffice, OptimisPT, HelloNote, SPRY, PtEverywhere, Jane and Tebra for outpatient clinics, and Epic or Oracle Health for hospital outpatient departments. Claims go out through your current clearinghouse. There is no migration. We sign a BAA, get user access, and check GP, CQ and KX logic, unit math and certification dates in your system before the first claim.
2 weeks
from a signed BAA to our team working your claims
About 3 weeks
to the first recovered payments on aged AR
20+ years
combined billing and coding experience
The treatment minutes in our notes did not consistently match the units submitted on the claim. Luxen added a daily validation step, reduced unit corrections by 76%, and recovered $33,900.
Clinical Director, outpatient physical therapy group
Plans of care and authorized visits were tracked separately at each clinic. Luxen centralized the process, reducing physical therapy charges held for expired documentation from $91,000 to $16,000.
Operations Director, multi-location rehabilitation practice
Full engagements are written up in our dental practice case study and our ambulance billing case study.
All three figures are Luxen client data, Jan 2024 to Jun 2026.
PTs bill remote therapeutic monitoring under a PT plan of care with GP. Two codes are new for 2026: 98985 for musculoskeletal device supply on 2 to 15 days in a 30-day period, and 98979 for the first 10 minutes of treatment management with at least one real-time interactive communication.
| Code | What it covers | 2026 national amount |
|---|---|---|
| 98975 | Initial setup and patient education on equipment | $21.71 |
| 98977 | Musculoskeletal device supply, 16 to 30 days | $51.44 |
| 98985 | Musculoskeletal device supply, 2 to 15 days | $51.44 |
| 98980 | Treatment management, first 20 minutes | $54.11 |
| 98979 | Treatment management, first 10 minutes | $26.39 |
Section 6209 of the Consolidated Appropriations Act, 2026 lets PTs furnish Medicare telehealth through December 31, 2027. For uninsured and self-pay patients, the No Surprises Act requires a Good Faith Estimate within 1 business day when a service is scheduled 3 to 9 business days out, and within 3 business days when it is scheduled 10 or more business days out. A bill at least $400 above the estimate can go to dispute. Our patient billing team handles estimates and statements, and plain-language statements plus text reminders raised patient collections 22% across 14 practices.
3% to 6% of collections
Luxen's pricing generally falls between 3% and 6% of collections, depending on claim volume, specialty, payer mix, and how much of the revenue cycle your practice hands over.
Higher-volume practices usually land toward the lower end. Smaller or more complex practices land higher because there is more work per account. There is no setup fee and no exit fee, and the agreement runs month to month with 30 days notice.
A lower fee attached to weak billing is still expensive. The number that matters is what your collections do after you hire someone.
Luxen charges 3% to 6% of collections, month to month with 30 days notice and no setup or exit fee. The rate depends on visit volume, payer mix and how much auto, workers compensation and aged AR is in scope.
The clinic has five PTs and three PTAs and collects $1,200,000 a year, or $100,000 a month: $960,000 from Medicare, Medicare Advantage and commercial plans, and $240,000 from auto and workers compensation. In our billing reviews, fully loaded in-house billing cost 7.9% of collections for practices under $2M, which is $94,800 a year here.
| Service line | Annual collections | In-house at 7.9% | Luxen at 3% | Luxen at 6% |
|---|---|---|---|---|
| Medicare, Medicare Advantage and commercial | $960,000 | $75,840 | $28,800 | $57,600 |
| Auto and workers compensation | $240,000 | $18,960 | $7,200 | $14,400 |
| Total per year | $1,200,000 | $94,800 | $36,000 | $72,000 |
| Total per month | $100,000 | $7,900 | $3,000 | $6,000 |
| Annual difference against in-house | None | $58,800 lower | $22,800 lower |
Turnover adds cost the table does not show: 34% of practice managers replaced a biller in the past two years (Luxen Practice Manager Survey 2026), and unit and KX errors pile up while the seat is empty.
Ask for a sample denial report before signing. In our survey, 42% of practice managers said nobody owns denial follow-up full time, and 63% could not name their top three denial reasons (Luxen Practice Manager Survey 2026).
| Partner type | PT unit, CQ and KX rules | Auto and work comp | Works in your EHR | Pricing |
|---|---|---|---|---|
| In-house biller | Depends on one person's training | Depends on staff experience | Yes | Salary, benefits and software |
| Generalist billing company | Varies; therapy may not be a focus | Varies | Varies | Percent of collections or per claim |
| Therapy specialty billing company | Usually a focus | Varies | Varies | Percent of collections or per claim |
| EHR vendor RCM | Tied to that EHR's rules engine | Varies | Only that EHR | Often bundled with software |
| Luxen | Payer-specific unit, GP, CQ and KX checks | Tracked with their own deadlines | Yes, no migration | 3% to 6% of collections, month to month |
To weigh other options side by side, compare medical billing companies in your state.
A 30-minute look at your AR ageing, denial reasons and payer mix. You leave knowing what is recoverable, what we would work first and what it would cost.
We sign a business associate agreement before anyone touches your system. Your named team then works inside the practice management system and clearinghouse you already use. Nothing is migrated, and claims are being worked within two weeks of the signed BAA.
Aged and denied claims come first because that is revenue you have already earned. Most practices see the first recovered payments inside three weeks.
Once the backlog is moving, we take over the agreed part of the daily cycle: eligibility, coding review, submission, posting, denials and patient balances.
You know who owns your claims. The team works inside the practice management system and EHR you already run, with no migration.
Claims are coded by certified coders against your documentation and payer rules. Automation handles the repetitive checks so people spend their time on the claims that need judgment.
We sign a business associate agreement before accessing protected health information, and access is limited to the named people on your account.
We look at your AR ageing, volume, payer mix and denial profile first, then tell you what we believe is recoverable and what it would cost.
A billing company is a poor fit if you are not willing to share visibility into your billing, if the vendor uses a rotating pool of people who never learn your practice, or if it cannot explain why your claims are being denied. Be wary of anyone promising large collection increases before they have seen your AR ageing. The right partner makes your revenue cycle more visible, not less.
Medicare adds all timed treatment minutes on the date of service and converts the total to 15-minute units, so 8 to 22 minutes bills 1 unit, 23 to 37 bills 2 and 38 to 52 bills 3 (Medicare Claims Processing Manual, Chapter 5, section 20.2). Three services of 10 minutes each total 30 minutes and bill 2 units, not 3.
Luxen charges 3% to 6% of collections, month to month, with no setup fee. For a PT clinic collecting $1,200,000 a year, that is $36,000 to $72,000 a year. In our billing reviews, in-house billing cost 7.9% of collections for practices under $2M, which would be $94,800 for the same clinic.
About 2 weeks from a signed BAA to working claims, with first recovered payments in about 3 weeks. Across our clients, the median time from signed BAA to first claims worked was 9 business days. We start with the oldest recoverable claims, beginning with auto PIP and commercial claims on short filing clocks.
We work inside WebPT, Raintree, Prompt, Net Health Therapy, TheraOffice, OptimisPT, SPRY, Jane and other therapy EHRs, plus Epic and Oracle Health in hospital outpatient departments. You do not need to switch: among practice managers who changed EHR or practice management systems, 71% said collections dipped for at least six months after the switch (Luxen Practice Manager Survey 2026).
Services furnished in whole or in part by the PTA carry CQ and pay at 85% of the fee schedule (42 CFR 410.60), unless the PTA share is 10% or less. In a CMS example, a PTA gives 10 minutes of 97110 and the PT gives 5, so the visit bills 1 unit of 97110 with CQ.
Thirty minutes, no deck and no fee. We look at what is sitting past 90 days and where your denials cluster, and you leave knowing what is recoverable, what we would work first, and what it would cost.
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