97110, 97112 or 97530: which code fits?

For OT and PT practice owners and billers seeing children, adults or both: bill 97110 when exercise builds strength, range, endurance or flexibility, 97112 when it retrains balance, coordination or posture, and 97530 for functional tasks. The purpose of the skilled work, not the equipment, picks the code. All three are timed 15-minute codes.⁠^1,2,3,4

What do 97110, 97112 and 97530 each describe?

They describe three timed, one-on-one therapeutic procedures that physical therapists and occupational therapists report in 15-minute units: exercise aimed at strength, endurance, range of motion or flexibility (97110); retraining of balance, coordination, body-position sense and posture (97112); and functional movement tasks practiced to restore how the patient performs everyday activities (97530).⁠^1,3,11 The American Medical Association owns CPT, and even CMS’s correct coding manual carries its copyright line, so this page summarizes each code in plain words and leaves the official wording to the current CPT codebook.⁠^8,12 Treat this guide as education only: what settles any claim is the payer’s written policy read with the CPT and HCPCS codes current for that visit, and a question about a single patient’s claim is one for that payer or a certified coder.

The targets in the third column come from the local coverage determination for outpatient PT and OT published by CGS Administrators, the Medicare Administrative Contractor for Jurisdiction 15, Kentucky and Ohio, revised for services on or after June 4, 2026.⁠¹ That policy governs Medicare claims in CGS’s jurisdiction. Other contractors publish their own policies and commercial plans write theirs, so read the distinctions below as one contractor’s text set beside CMS’s manuals, then check your own payers’ policies.

Who may report 97110, 97112 and 97530?

Physical therapists and occupational therapists, each under their own plan of care. CMS lists all three as always-therapy codes, carrying GP under a PT plan of care or GO under an OT plan, and its manual says those modifiers do not let anyone deliver a service Medicare does not recognize them to perform.⁠^3,13 AOTA lists the three among the codes OT practitioners use frequently to report skilled services, and APTA says a PT can bill any code that state licensure and payer policy permit.⁠^11,12

Speech-language pathologists are the exception under Medicare. NCCI’s chapter on medicine services says SLPs do not perform services coded as 97110, 97112 or 97530, which PTs and OTs generally perform, and may not report them as unbundled parts of 92507, 92508 or 92526.⁠⁸ Washington’s Medicaid billing guide marks the three codes for PT and OT, with GP or GO, and leaves the speech column empty.⁠⁴

Why does the purpose, not the equipment, decide the code?

Because one piece of equipment can serve three purposes. CGS’s policy codes a gym ball exercise done to increase strength as therapeutic exercise and the same gym ball exercise done to improve balance as neuromuscular re-education, and it counts taping used to enhance proprioception under neuromuscular re-education.⁠¹ Its billing article states the rule outright: choose the code that most accurately describes the service actually provided or the intention of the treatment toward the goal, never the code with the higher payment.⁠²

A balance beam, a climbing wall or a wobble board could sit under any of the three codes; the note decides which by saying what the therapist was working on and why. Under Medicare’s manual, a diagnosis or prognosis alone never settles whether a service is skilled.⁠⁵ Code choice deserves the same caution: a stroke does not make every session 97112, and a fracture does not make every session 97110.

When is an exercise skilled enough to bill as 97110?

When the exercise targets a measured loss of strength, endurance, range of motion or flexibility that limits function, and a therapist’s judgment is needed to choose, grade, progress or teach it. CGS’s policy includes active, active-assisted and passive exercise for those purposes and says many exercises need a therapist to evaluate the patient, design the program and teach it safely; once the teaching is done, repetition and monitoring without further skilled care are not covered.⁠¹

Its example is a patient after a total knee replacement on an exercise bike. While the therapist is progressing from rocking the pedals to full revolutions and adjusting seat height and resistance, the time is skilled; once the patient rides safely without frequent assessment, the bike is an independent program, and a warm-up on it stays out of the timed minutes even when the therapist sets it up.⁠¹ Exercise for general fitness and flexibility is not a therapy service under Medicare at all.⁠⁵

CGS asks the record for objective measures of lost strength and range compared with the other side and their effect on function, the specific exercises, their purpose in terms of function, the instruction given and the assistance needed.⁠¹ It also asks the record to show exercises moving to an independent or caregiver-assisted program as clinically indicated, and it says a lack of equipment at home does not make continued clinic exercise skilled.⁠¹

• A child after a cast: a 9-year-old whose forearm cast came off three weeks ago works on grip and wrist strength with graded putty and light weights; the therapist sets the resistance from today’s grip measure and corrects wrist substitution, so the purpose is strength and the code is 97110.⁠¹
• An adult after knee surgery: a 66-year-old six weeks after a knee replacement works on knee bending and quadriceps strength while the PT progresses the load and range from today’s measures and pain response; the code is 97110.⁠¹
• Not 97110: the same adult pedaling alone while the PT treats someone else; those minutes are not billable under any code.⁠^1,2

When is balance or coordination training billed as 97112?

When the goal is to restore or maintain balance, coordination, kinesthetic sense, posture or proprioception, and the therapist is grading the challenge, facilitating the movement or choosing the input. CGS names proprioceptive neuromuscular facilitation, balance boards, vestibular rehabilitation, desensitization techniques and balance and posture training as examples.⁠¹ It lists the problems that can make the service reasonable and necessary: neuropathy with lost reflexes and vibration sense, nerve palsy such as foot drop, weakness from brain, nerve or spinal cord injury or disease, poor sitting or standing balance, postural abnormalities, lost gross or fine motor coordination, and low or high tone.⁠¹

For a patient referred because of falls, CGS asks the record for the fall history, prior mobility, cognition, earlier therapy, the recent loss of function, balance testing, preferably standardized, strength and range testing, caregiver training and carryover. It also says that extending visits only to repeat cues already taught or to remind a patient to ask for help may not be reasonable and necessary, because repetitive cues and reminders do not need a therapist.⁠¹

Vestibular rehabilitation, which CGS lists under 97112, brings an edit of its own. When a therapist performs canalith repositioning, 95992, NCCI says the code includes everything needed for the repositioning, and 97110, 97112, 97140 and 97530 are not reported separately for services related to it; in the October 1, 2026 file, 95992 is column one over all three, with a modifier allowed for a separate service.⁠^7,8 CMS lists 95992 as a sometimes-therapy code, which becomes a therapy service when a therapist furnishes it.⁠¹³

• A child with low tone: a 5-year-old practices single-leg stance and beam walking while the PT changes the surface and visual input and facilitates trunk control; the purpose is balance, so the code is 97112.⁠¹
• An adult at risk of falls: a 78-year-old practices stepping reactions to perturbations the PT chooses, times and grades; the purpose is standing balance, so the code is 97112.⁠¹
• An adult after a stroke: a 61-year-old works on weight shift and trunk control in sitting while the OT facilitates the movement; the purpose is postural control, so the code is 97112.⁠¹

What sets therapeutic activities, 97530, apart from exercise?

Function. 97530 fits when the patient practices a dynamic task, such as lifting, carrying, reaching, catching, pushing, a transfer or bed mobility, to restore or maintain performance, and the therapist designs the task around a specific functional need and teaches it. CGS says the activities must belong to an active treatment plan aimed at a specific outcome, and it covers them only when three conditions hold: a documented condition the activities can reasonably be expected to help, a clear link between the activity and that condition, and a patient who cannot do the activity without skilled help.⁠¹

CGS describes the activities as usually directed at lost mobility, strength, balance or coordination, so the line with 97110 and 97112 again runs through the purpose.⁠¹ A sit-to-stand drilled to load the quadriceps is exercise; the same movement practiced so the patient can rise from a low toilet or a car seat safely is a functional task. CGS asks the record for objective measures of lost daily-living skills, balance, strength, coordination, range and mobility and their effect on function, plus the specific activities and the amount and type of assistance.⁠¹

• A child’s play, built toward a goal: a 7-year-old with developmental coordination disorder runs a climb, crawl and carry course the OT built so she can keep up at recess, with the OT changing the sequence as she plans her movements; the target is a functional skill, so the code is 97530.⁠¹
• A child on the school stairs: a 10-year-old with cerebral palsy practices carrying a backpack up and down stairs while the PT grades the load and the handhold; 97530.⁠¹
• An adult after a stroke: wheelchair-to-toilet transfers and reaching into kitchen cabinets while standing, with the OT setting heights and cueing weight shift; 97530.⁠¹
• An adult going back to work: lifting and carrying boxes with body mechanics the PT teaches and grades; 97530.⁠¹

When an OT session trains the self-care task itself, such as dressing, bathing or toileting, a different code may describe it better; the OT procedure codes guide sets out where 97530 ends and the self-care code begins. Sensory integrative treatment is a separate always-therapy code, 97533, with its own payer questions, covered in the 97533 guide.⁠¹³

What makes a service skilled rather than unskilled under Medicare?

The need for a therapist’s judgment, not the credential of the person in the room. Medicare’s Benefit Policy Manual says a service is not skilled merely because a therapist furnishes it; a service that can be self-administered or safely done by an unskilled person is not skilled even when a therapist does it, and services that do not need a therapist’s performance or supervision are not reasonable or necessary therapy.⁠⁵ The manual also rules out exercise meant for general fitness or flexibility, and activities meant to divert or motivate, and it frames the key question as whether a therapist’s skills are needed or the service can be carried out by nonskilled personnel.⁠⁵

Two more rules shape the codes on the claim. Services by aides are not therapy services under Medicare even under a therapist’s supervision, and timed codes need direct one-on-one contact, so minutes spent supervising a patient who exercises alone are not billable.⁠^2,5 The manual adds that a clinician may not merely supervise, but must actively take part in treatment during each progress report period, which runs no longer than 10 treatment days.⁠⁵

Can maintenance exercise be billed as 97110 or 97112?

Yes, when the maintenance program needs a therapist’s skills. CMS’s page on the Jimmo settlement says skilled therapy is covered when an individualized assessment shows that a qualified therapist’s judgment, knowledge and skills are needed for a safe and effective maintenance program, and that what decides coverage is the patient’s need for skilled care rather than any prospect of improvement.⁠¹⁴ The manual covers a therapist designing the program, teaching it and reassessing it; once the patient or a helper can carry it out, the sessions are not covered unless the procedures are too complex for anyone but a therapist or the patient’s medical complications need one, as with range-of-motion exercise for an unhealed, unstable fracture.⁠⁵ The settlement leaves the other coverage rules, such as reasonable and necessary care, in place.⁠¹⁴ What this means for patients is set out in the Medicare therapy coverage guide.

What must a treatment note show to support the skilled code?

For Medicare, the note for each treatment day identifies every intervention, timed or untimed, in language a reviewer can compare with the billed codes, lists each timed service whether or not it earned a unit, and gives total timed code minutes and total treatment time; descriptions of skilled work belong in the plan or progress reports and are allowed, but not required, in the daily note.⁠⁵ The manual says skill can be shown by describing the skilled treatment, the changes made after assessing the patient that day, or the progression toward a harder task, and that new or changed exercises help show the services are skilled.⁠⁵

CGS warns that a list of exercise names, such as pulleys or straight-leg raises, does not by itself show skilled treatment, especially across many sessions, and that a functional result such as walking 35 feet with minimal assistance does not either; it asks practices to document the skilled components from time to time so the care does not read as repetitive.⁠² It also asks for CMS’s own terms, total Timed Code Treatment Minutes and Total Treatment Time, recorded as actual minutes rather than rounded ones, with no single time-in and time-out for the whole session.⁠² Some payers ask for more: Washington’s Medicaid guide wants start and end times for each timed code.⁠⁴ A short skilled-service sentence on each timed line is a compact way to show the therapist’s part on every day a reviewer reads.

How do the three codes share timed minutes on one day?

Under Medicare, by the day’s total: add the minutes of every 15-minute timed code, read the units from the manual’s table, give each code that ran 15 minutes or more its full units, then give any remaining unit to the code with the most minutes left over.⁠^2,3 The eight-minute rule guide works through the full table, other payers’ methods and the assistant rules; this section shows only how these three codes sit together.

CMS’s first example uses two of them: 24 minutes of 97112 and 23 of 97110 make 47 minutes, three units, billed as two of 97112 and one of 97110 because 97112 took longer; with 20 minutes of each, either code may take two units and the other one, but neither takes all three.⁠³ CGS’s billing article works the same case by 15-minute blocks, giving the third unit to 97112’s 9 leftover minutes over 97110’s 8.⁠² A hypothetical adult PT session with all three shows the order of work:

• Minutes: 20 of transfer practice (97530), 12 of standing balance work (97112) and 9 of hip strengthening (97110), 41 timed minutes in all, which is three units.⁠³
• Full units first: only 97530 reached 15 minutes, so it takes one unit with 5 minutes left over.⁠³
• Leftovers: 97112 has 12 minutes and 97110 has 9, both more than 97530’s 5, so each takes one of the two remaining units: one unit each of 97530, 97112 and 97110.⁠^2,3

Two ceilings sit on top of the count. Medicare’s practitioner unit edits effective October 1, 2026 allow 6 units of 97110, 4 of 97112 and 6 of 97530 per day, and NCCI describes them as per-day clinical edits that a contractor may bypass on review when the extra units were provided, coded correctly and medically necessary.⁠^6,9 CGS’s billing article sets its own line in its jurisdiction, no more than 4 units of each of the three per day per discipline, below the national edit for 97110 and 97530, with denials open to appeal.⁠²

Other payers can count differently. APTA notes that CPT’s time guidelines allow a unit each time a code’s midpoint is passed, without totaling the day, and tells practices to read each payer’s policy to learn which method applies; Washington’s Medicaid guide equates one unit with each 15 minutes of a timed code.⁠^4,15

Which same-day edits apply to 97110, 97112 and 97530 in 2026?

In the Medicare practitioner edit file effective October 1, 2026, version 323r0, none apply between the three codes themselves, and none between them and 97140, 97116, 97533, 97535 or any PT or OT evaluation or re-evaluation code. Where a live pair does involve them, Medicare pays the column one code and denies the column two code unless the edit permits a modifier and the record supports one.⁠⁷ The file was posted September 2, 2026, and CMS changes the edit files every quarter, so check each new quarter’s file.⁠⁷ Indicator 0 shuts the pair off whatever modifier is used; indicator 1 lets a modifier through when the circumstances support it.⁠⁹

The table lists the live pairs an outpatient PT or OT practice is most likely to meet; the same file also pairs the three codes with biofeedback, injection, nerve block and home health codes.⁠⁷ Pairs that were once edits keep their rows with deletion dates: 97140 with 97530 ended December 31, 2019, 97530 with 97533 and with 97535 ended December 31, 2021, and the rows pairing the three codes with the re-evaluation codes 97164 and 97168 stopped at December 31, 2019, while the rows that replaced them were closed the day they opened, October 1, 2020.⁠⁷ NCCI gives every pair whose deletion date equals its effective date the indicator 9, and APTA reads those rows as inactive, so the combination is billable without a modifier.⁠^9,16

No edit does not mean the minutes may overlap. NCCI bars reporting more than one physical medicine service for the same 15 minutes, supervised modalities excepted, says its edits do not cover every pair that cannot share those minutes, and expects correct coding even where no edit exists.⁠⁸ NCCI also tells therapists not to bill a re-evaluation as a routine step within a planned course of PT or OT; the PT evaluation codes guide and the OT evaluation codes guide cover when a re-evaluation is billable.⁠⁸

Two notes on the file itself. APTA says it asked CMS on May 21, 2026 to delete the edits pairing 97150 with the one-on-one codes, 97110, 97112 and 97530 among them, and the edit pairing 95992 with 97112; those edits remain live in the October 1, 2026 file.⁠^7,16 APTA also explains that the practitioner edits apply to claims from PTs in private practice, while the hospital edits apply to outpatient hospital, comprehensive outpatient rehabilitation facility and other institutional claims, so an institutional practice checks the hospital file, which this guide does not tabulate.⁠¹⁶

When may modifier 59 or XU separate two of these services?

Only on an edit with indicator 1, and only when the two services ran in different timed intervals that the note shows. NCCI’s chapter on medicine services allows 59 or XU on a physical medicine pair when the two procedures occupied different timed intervals, including back-to-back intervals in one visit.⁠⁸ Its general chapter adds that the time blocks may be sequential or split, that Medicare’s timed-unit rules still apply to the total, and that a practitioner may not perform several services each for the minimum reportable time and report each as a unit.⁠⁹

The same chapter forbids adding a modifier just to get past an edit, says a different diagnosis does not justify 59, and requires the record to satisfy each modifier’s criteria; it defines XU as a service distinct because it does not overlap the usual components of the main service.⁠⁹ Medicare’s edits govern Medicare claims, so ask each Medicaid program, managed care plan and commercial plan which edits and modifiers it applies, and keep the answer in its file.

How do children’s and adults’ claims for these codes differ?

The codes and the purpose test stay the same; the payer and its limits change. Neither CMS’s therapy code list nor Washington’s Medicaid guide reserves the three codes for one age group.⁠^4,13 For an adult on Original Medicare Part B, the discipline of the plan of care sets GP or GO, the day’s timed minutes set the units, and the Benefit Policy Manual’s skilled-care rules apply.⁠^3,5 For an adult in a Medicare Advantage plan, read the plan’s provider manual for its unit method, edits and authorization steps before the first visit.

For a child in Medicaid, the EPSDT benefit obliges the state to cover any federally coverable Medicaid service a child needs to treat, correct or reduce a condition, even one its state plan leaves out, with medical necessity judged child by child.⁠¹⁰ Washington’s program shows how one state handles these codes: its July 10, 2026 billing guide lists 97110, 97112 and 97530 as timed 15-minute PT and OT codes billed with GP or GO, covers unlimited outpatient rehabilitation for eligible clients 20 and younger, except for clients aged 19 or 20 in its Medical Care Services program, and counts all three codes toward the yearly limit for clients 21 and older.⁠⁴ The EPSDT guide covers what states owe children under 21.

Medicare’s definition of skilled care is Medicare’s; a state Medicaid program decides medical necessity case by case, and each payer chooses its own unit method.⁠^10,15 Ask each plan, in writing if possible, how it counts timed units, whether it applies NCCI edits, and what it wants in the note, and record the answer, the day and its source in that plan’s file. For a child, the goal may be participation at home, at school or in play, and the note still has to say whether the session built strength, trained balance or practiced the functional task itself.

Which activity matches which code, and what does the note say?

Start from what the patient did and what the therapist did, name the purpose, and the code follows; the table pairs pediatric and adult cases, and the last column is a sentence a note could carry.⁠^1,2

How would one child’s and one adult’s sessions be coded?

Each session below is coded from the note: the purpose of each activity, the minutes, the units, then the edits. Both are hypothetical, and the payer rules in them are inputs, not statements about a real plan.

Which errors put 97110, 97112 and 97530 claims at risk?

The ones CMS’s manuals, the NCCI manual and CGS’s policy name directly. Check each claim against this list before it goes:

• Counting independent or supervised time: minutes a patient exercises alone, or rides the bike after the teaching is done, are not billable and stay out of the timed total.⁠^1,2
• Exercise lists without skill: exercise names or functional results alone do not show skilled treatment.⁠²
• The same minutes under two codes: two of these codes cannot be billed for the same 15 minutes, whether for one patient or for two.⁠^2,8
• Both co-treating clinicians billing the same time: therapists or assistants treating one patient together cannot each bill separately for the same time.⁠²
• Choosing by payment: picking a code for its payment amount rather than the service provided or its intended outcome.⁠²
• Splitting one service into several codes: CGS names unbundling among the errors to avoid.⁠²
• A modifier to get past an edit: 59 or XU without separate time blocks, or justified only by a different diagnosis.⁠⁹
• Repeating cues already taught: visits extended for reminders and routine cues may not be reasonable and necessary.⁠¹
• Long courses without support: in its jurisdiction, CGS asks the record to clearly support 97110 or 97112 beyond 12 to 18 visits and 97530 beyond 10 to 12.⁠¹
• Aide minutes: services by aides are not therapy services under Medicare.⁠⁵

To check your own claims, pull a sample of notes from each clinician on a set schedule, read every timed line against this list and the decision table, and write down what the review showed and what the practice changed.

Sources

1. CGS Administrators, LLC, Medicare Administrative Contractor for Jurisdiction 15, Parts A and B (Kentucky and Ohio). Local Coverage Determination L34049, Outpatient Physical and Occupational Therapy Services (Medicare Coverage Database; original effective date October 1, 2015; revision effective for services on or after June 4, 2026; Therapeutic Procedures). Checked October 25, 2026.
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   “Use of these procedures requires the qualified professional/auxiliary personnel to have direct (one-on-one) patient contact.”; “Supervision of a previously taught exercise or exercise program, patients performing an exercise independently without direct contact by the qualified professional/auxiliary personnel, or use of different exercise equipment without requiring the intervention/skills of the qualified professional/ auxiliary personnel are not covered.”; “The patient may be in the facility for a longer period of time, but only the time the qualified professional/auxiliary personnel is actually providing direct, one-on-one, patient contact which requires the skills of a therapist is considered covered time for these procedures, and only those minutes of treatment should be recorded.”; “documentation must support the use of each procedure as it relates to a specific therapeutic goal.”; “Therapeutic exercises are used for the purpose of restoring or maintaining strength, endurance, range of motion and flexibility where loss or restriction is a result of a specific disease or injury and has resulted in a functional limitation. Therapeutic exercises may require active, active-assisted, or passive participation by the patient”; “Many therapeutic exercises may require the unique skills of a therapist to evaluate the patient’s abilities, design the program, and instruct the patient or caregiver in safe completion of the special technique. However, after the teaching has been successfully completed, repetition of the exercise, and monitoring for the completion of the task, in the absence of additional skilled care, is non-covered.”; “Initially the patient requires skilled progression in the program from pedal-rocks, building to full revolutions, perhaps assessing and varying the seat height and resistance along the way. Once the patient is able to safely exercise on the bike, no longer requiring frequent assessment and progression, even if set up is required, the bike now becomes an “independent” program and is no longer covered by Medicare.”; “it is considered a non- skilled, unbillable service and should not be included in the total timed code treatment minutes.”; “Documentation must also show that exercises are being transitioned as clinically indicated to an independent or caregiver- assisted exercise program”; “Lack of exercise equipment at home does not make continued treatment in the clinic skilled or reasonable and necessary.”; “For example, a gym ball exercise used for the purpose of increasing the patient’s strength should be considered as therapeutic exercise when coding for billing.”; “Documentation must clearly support the need for continued therapeutic exercise greater than 12-18 visits.”; “Objective measurements of loss of strength and range of motion (with comparison to the uninvolved side) and effect on function”; “Specific exercises performed, purpose of exercises as related to function, instructions given, and/or assistance needed to perform exercises to demonstrate that the skills of a therapist were required”; “This therapeutic procedure is provided for the purpose of restoring or maintaining balance, coordination, kinesthetic sense, posture, and proprioception (e.g., proprioceptive neuromuscular facilitation (PNF), BAP’s boards, vestibular rehabilitation, desensitization techniques, balance and posture training).”; “loss of deep tendon reflexes and vibration sense accompanied by paresthesia, burning, or diffuse pain of the feet, lower legs, and/or fingers;”; “nerve palsy, such as peroneal nerve injury causing foot drop;”; “muscular weakness or flaccidity as result of a cerebral dysfunction, a nerve injury or disease or having had a spinal cord disease or trauma;”; “poor static or dynamic sitting/standing balance;”; “postural abnormalities;”; “loss of gross and fine motor coordination;”; “hypo/hypertonicity.”; “For example, a gym ball exercise used for the purpose of improving balance should be considered as neuromuscular reeducation when coding for billing. The minutes spent taping, such as McConnell taping or kinesiotaping techniques, to enhance proprioception would be counted under neuromuscular re-education code.”; “When therapy is instituted because there is a history of falls or a falls screening has identified a significant fall risk, documentation should indicate:”; “specific fall dates and/or hospitalization(s) and reason for the fall(s), if known; most recent prior functional level of mobility, including assistive device, level of assist, frequency of falls or “near-falls”;”; “cognitive status;”; “prior therapy intervention;”; “functional loss due to the recent change in condition;”; “balance assessments (preferably standardized), lower extremity ROM and muscle strength testing;”; “patient and caregiver training;”; “carry-over of therapy techniques to objectively document progress.”; “It may not be reasonable and necessary to extend visits for a patient with falls, or any patient receiving therapy services, if the purpose of the extended visits is to:”; “remind the patient to ask for assistance;”; “offer routine verbal cues for compensatory or adaptive techniques already taught;”; “repetitive cues and reminders do not require the skills of a therapist.”; “Documentation must clearly support the need for continued neuromuscular reeducation greater than 12-18 visits.”; “If the therapist is dividing attention among the patients, providing only brief, intermittent personal contact, or giving the same instructions to two or more patients at the same time, one unit is appropriate per patient.”; “This procedure involves the use of functional activities (e.g., bending, lifting, carrying, reaching, catching, pushing, pinching, grasping, transfers, bed mobility and overhead activities) to restore or maintain functional performance. The activities are usually directed at a loss or restriction of mobility, strength, balance, or coordination. They require the skills of the therapist to design the activities to address a specific functional need of the patient and to instruct the patient in their performance. These dynamic activities must be part of an active treatment plan and must be directed at a specific outcome.”; “the patient has a documented condition for which therapeutic activities can reasonably be expected to restore or maintain functioning;”; “there is a clear correlation between the type of therapeutic activity performed and the patient’s underlying medical condition;”; “the patient’s condition is such that he/she is unable to perform the therapeutic activities without the skilled intervention of the qualified professional/auxiliary personnel.”; “Documentation must clearly support the need for continued therapeutic activity treatment beyond 10-12 visits.”; “Objective measurements of loss of ADLs, balance, strength, coordination, range of motion, mobility and effect on function”; “Specific activities performed, and amount and type of assistance to demonstrate that the skills and expertise of the therapist were required”.
2. CGS Administrators, LLC, Medicare Administrative Contractor for Jurisdiction 15, Parts A and B (Kentucky and Ohio). Billing and Coding: Outpatient Physical and Occupational Therapy Services, A57067 (Medicare Coverage Database billing and coding article for LCD L34049; original effective date September 19, 2019; revision effective June 4, 2026). Checked October 25, 2026.
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   “Listing of exercise names (e.g., pulleys, UBE, TKE, SLR) does not alone imply that skilled treatment has been provided, especially if the exercises have been performed over multiple sessions. Be sure to occasionally document the skilled components of the exercises so they do not appear repetitive and therefore, unskilled.”; “Documenting functional activities performed (e.g., “ambulated 35 feet with min assist”, “upper body dressing with set up and supervision”) also does not alone imply that skilled treatment was provided.”; “description of the skilled components of the specific exercises, training, or activities;”; “When documenting treatment time, consistently use the CMS language of total “Timed Code Treatment Minutes” and “Total Treatment Time”.”; “Do not record treatment time as “Time in / Time out” for the entire session as this does not accurately reflect the actual treatment time. Do not “round” all treatments to 15-minute increments, but rather record the actual treatment time.”; “Time spent “supervising” a patient performing an activity that is defined as a timed code, or for the patient to perform an independent activity, even if a therapist is providing the equipment, is considered unbillable time and these minutes should not be counted in the “Timed Code Treatment Minutes.””; “Therapy timed services require direct, one-on-one patient qualified professional/auxiliary personnel contact, and by definition cannot be billed when performed in a supervised manner.”; “24 minutes 97112 = one 15-minute block + 9 remaining minutes”; “Since the total minutes allows for 3 units, the third unit shall be applied to the service with the most “remaining minutes” (97112 has 9 remaining minutes, whereas, 97110 has 8 remaining minutes).”; “Do not select the HCPCS/CPT code based on the reimbursement amount associated with a particular HCPCS/CPT. Rather select the HCPCS/CPT based on the code that most accurately describes the service actually provided and/or the intention of the treatment to achieve the desired outcome/goal.”; “Do not “unbundle” services/procedures.”; “Therapists, or therapy assistants, working together as a “team” to treat a patient cannot each bill separately for the same or different service provided at the same time to the same patient.”; “in the same time period (such as from 1:00 to 1:15) a clinician cannot bill any of the following pairs of CPT codes for therapy services provided to the same, or to different patients.”; “The following interventions should be reported no more than 4 (four) units per code per day per discipline; additional units will be denied:”; “Denials due to the limits described in this section of the LCD may be appealed.”; the 4-unit list includes 97110, 97112 and 97530.
3. Centers for Medicare & Medicaid Services. Medicare Claims Processing Manual, Chapter 5, Part B Outpatient Rehabilitation and CORF/OPT Services (Pub. 100-04; §20.1 and §20.2, Rev. 3670, effective January 1, 2017). Checked October 25, 2026.
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   “Therapy modifiers are GP for physical therapy, GO for occupational therapy, and GN for speech-language pathology.”; “These modifiers do not allow a provider to deliver services that they are not qualified and recognized by Medicare to perform.”; “The claim must include one of the following modifiers to distinguish the discipline of the plan of care under which the service is delivered:”; “HCPCS “timed” code 97530 which is defined in 15 minute units”; “providers bill a single 15-minute unit for treatment greater than or equal to 8 minutes through and including 22 minutes.”; “3 units: ≥ 38 minutes through 52 minutes”; “If a service represented by a 15 minute timed code is performed in a single day for at least 15 minutes, that service shall be billed for at least one unit.”; “When more than one service represented by 15 minute timed codes is performed in a single day, the total number of minutes of service (as noted on the chart above) determines the number of timed units billed.”; “24 minutes of neuromuscular reeducation, code 97112, 23 minutes of therapeutic exercise, code 97110, Total timed code treatment time was 47 minutes.”; “The correct coding is 2 units of code 97112 and one unit of code 97110, assigning more timed units to the service that took the most time.”; “Since the time for each service is the same, choose either code for 2 units and bill the other for 1 unit. Do not bill 3 units for either one of the codes.”; “Compare the remaining time for 97110 (33-30 = 3 minutes) to the time spent on 97140 (7 minutes) and bill the larger, which is 97140.”; “You would still document the ultrasound in the treatment notes.”; “indicates that the amount of time for each specific intervention/modality provided to the patient is not required to be documented in the Treatment Note. However, the total number of timed minutes must be documented.”.
4. Washington State Health Care Authority. Washington Apple Health (Medicaid) Outpatient Rehabilitation Billing Guide (July 10, 2026). Checked October 25, 2026.
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   “Each 15 minutes of a timed CPT® code equals one unit.”; “The client’s medical record must include detailed documentation for each timed CPT® code, specifying the date of service with the therapy modality start and end times.”; “For eligible clients age 20 years and younger, the Health Care Authority covers unlimited outpatient rehabilitation, with the exception of clients age 19 through 20 receiving Medical Care Services (MCS).”; “* = Included in the benefit limitation for all clients age 21 and over and MCS clients age 19 through 20.”; “Providers must use the appropriate modifier when billing the Health Care Authority”; its coverage table lists 97110, 97112 and 97530 each with that asterisk, the modifiers GP and GO, marks in the PT and OT columns and none in the SLP column, and the comment “Timed 15 min units”.
5. Centers for Medicare & Medicaid Services. Medicare Benefit Policy Manual, Chapter 15, Covered Medical and Other Health Services (Pub. 100-02, Rev. 13889, issued July 30, 2026; §220.2 A to D, §220.3 B, D and E, and §230.1 C). Checked October 25, 2026.
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   “A service is not considered a skilled therapy service merely because it is furnished by a therapist or by a therapist/therapy assistant under the direct or general supervision, as applicable, of a therapist.”; “If a service can be self-administered or safely and effectively furnished by an unskilled person, without the direct or general supervision, as applicable, of a therapist, the service cannot be regarded as a skilled therapy service even though a therapist actually furnishes the service.”; “services related to activities for the general good and welfare of patients, e.g., general exercises to promote overall fitness and flexibility and activities to provide diversion or general motivation, do not constitute therapy services for Medicare purposes.”; “Services that do not require the performance or supervision of a therapist are not skilled and are not considered reasonable or necessary therapy services, even if they are performed or supervised by a qualified professional.”; “a beneficiary’s diagnosis or prognosis cannot be the sole factor in deciding that a service is or is not skilled. The key issue is whether the skills of a therapist are needed to treat the illness or injury, or whether the services can be carried out by nonskilled personnel.”; “the establishment or design of a maintenance program by a qualified therapist is covered.”; “If skilled therapy services by a qualified therapist are needed to instruct the patient or appropriate caregiver regarding the maintenance program, such instruction is covered. If skilled therapy services are needed for periodic reevaluations or reassessments of the maintenance program, such periodic reevaluations or reassessments are covered.”; “A maintenance program can generally be performed by the beneficiary alone or with the assistance of a family member, caregiver or unskilled personnel. In such situations, coverage is not provided.”; “the therapy procedures required to maintain the patient’s current function or to prevent or slow further deterioration are of such complexity and sophistication that the skills of a qualified therapist are required to furnish the therapy procedure”; “the particular patient’s special medical complications require the skills of a qualified therapist to furnish a therapy service required to maintain the patient’s current function or to prevent or slow further deterioration”; “Where there is an unhealed, unstable fracture that requires regular exercise to maintain function until the fracture heals, the skills of a therapist may be needed to ensure that the fractured extremity is maintained in proper position and alignment during range of motion exercises.”; “A clinician may not merely supervise, but must apply the skills of a therapist by actively participating in the treatment of the patient during each progress report period.”; “a therapist’s skills may be documented, for example, by the clinician’s descriptions of their skilled treatment, the changes made to the treatment due to a clinician’s assessment of the patient’s needs on a particular treatment day or changes due to progress the clinician judged sufficient to modify the treatment toward the next more complex or difficult task.”; “The minimum progress report period shall be at least once every 10 treatment days.”; “Descriptions of skilled interventions should be included in the plan or the progress reports and are allowed, but not required daily.”; “Identification of each specific intervention/modality provided and billed, for both timed and untimed codes, in language that can be compared with the billing on the claim to verify correct coding. Record each service provided that is represented by a timed code, regardless of whether or not it is billed, because the unbilled timed services may impact the billing;”; “Total timed code treatment minutes and total treatment time in minutes.”; “New exercises added or changes made to the exercise program help justify that the services are skilled.”; “Services provided by aides, even if under the supervision of a therapist, are not therapy services and are not covered by Medicare.”.
6. Centers for Medicare & Medicaid Services. Medicare NCCI Medically Unlikely Edits (MUEs) (page last modified August 31, 2026, with the Practitioner Services MUE Table effective October 1, 2026). Checked October 25, 2026.
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   “An MUE is the maximum units of service (UOS) reported for a HCPCS/CPT code on the vast majority of appropriately reported claims by the same provider/supplier for the same beneficiary on the same date of service.”; “Practitioner Services MUE Table (ZIP) - Effective October 1, 2026; Posted September 1, 2026”; the table gives 97110 a value of 6, 97112 a value of 4 and 97530 a value of 6, each with MUE adjudication indicator 3, “Date of Service Edit: Clinical”.
7. Centers for Medicare & Medicaid Services. Medicare NCCI Procedure to Procedure (PTP) Edits (page last modified September 1, 2026; 2026 Quarter 4 practitioner files, version 323r0, read in full). Checked October 25, 2026.
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   “If a provider reports the two codes of an edit pair for the same beneficiary on the same date of service, the Column One code is eligible for payment, but the Column Two code is denied unless a clinically appropriate NCCI PTP-associated modifier is also reported.”; “CMS posts changes to each of its NCCI PTP published edit files on a quarterly basis.”; “Practitioner PTP Edits v323r0 (612,539 Records) 62292/01912 -- U0003/U0004 - Effective Oct. 1, 2026; Posted September 2, 2026”; in that file (column one/column two, then the modifier indicator, where 0 is not allowed and 1 is allowed), the live rows (no deletion date) that pair 97110, 97112 or 97530 with another therapy, speech or rehabilitation code are: 97150 with 97110, 97112 and 97530, indicator 1; 92507, 92508 and 92526 each with 97110, 97112 and 97530, indicator 1; 95992 with 97110, 97112, 97140 and 97530, indicator 1; 97755 with 97110, 97112 and 97530, indicator 1; 97760, 97761 and 97763 each with 97110 and 97112, indicator 1; 97113 with 97110, indicator 1; 97112 with 97022 and 97036, indicator 1; 97530 with 97537, 97542 and 97750, indicator 1; 97530 with 95851 and 95852, indicator 0; 97530 with 97153, 97154, 97155, 97156, 97157 and 97158, indicator 0; 90912 and 90913 each with 97110, 97112 and 97530, indicator 1; 93797, 93798, G0422, G0423, 94625, 94626, G0237, G0238 and G0239 each with 97110, 97112 and 97530, indicator 1; no row pairs any two of 97110, 97112 and 97530, and no row pairs any of them with 97116, 97140, 97533, 97535 or 97161 to 97168 without a deletion date; the pair 97140/97530 carries a deletion date of December 31, 2019, the pairs 97530/97533 and 97530/97535 carry a deletion date of December 31, 2021, the pairs 97530/97110, 97530/97112, 97110/97140 and 97112/97140 carry indicator 9 with a deletion date equal to the effective date, the rows pairing 97530 with 97161, 97162, 97163, 97165, 97166 and 97167 carry indicator 9 with a deletion date equal to their effective date of January 1, 2020, and the rows pairing 97110, 97112 and 97530 with 97164 and 97168 carry a deletion date of December 31, 2019, their later rows indicator 9 with a deletion date equal to the effective date of October 1, 2020; the file also pairs the three codes with injection, nerve block and home health codes.
8. Centers for Medicare & Medicaid Services. NCCI Policy Manual for Medicare Services, Chapter XI, Medicine and Evaluation and Management Services (effective January 1, 2026; revision date 1/1/2026; sections H.2, H.8, P.1 to P.3 and P.7). Checked October 25, 2026.
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   “Current Procedural Terminology (CPT) codes, descriptions and other data only are copyright 2025 American Medical Association. All rights reserved.”; “Speech language pathologists may perform services coded as CPT codes 92507, 92508, or 92526. They do not perform services coded as CPT codes 97110, 97112, 97150, or 97530 which are generally performed by physical or occupational therapists.”; “Speech language pathologists shall not report HCPCS/CPT codes 97110, 97112, 97150, 97530, as unbundled services included in the services coded as 92507, 92508, or 92526.”; “CPT code 95992 describing canalith repositioning procedure(s) is reported with no more than one unit of service per day and includes all services necessary to achieve the canalith repositioning. Other CPT codes (e.g., 97110, 97112, 97140, 97530) shall not be reported separately for services related to the canalith repositioning.”; “With one exception, providers/suppliers shall not report more than one physical medicine and rehabilitation therapy service for the same fifteen-minute time period.”; “These edits may be bypassed with modifier 59 or XU if the 2 procedures of a code pair edit are performed in different timed intervals even if sequential during the same patient encounter.”; “The NCCI program does not include all edits pairing 2 physical medicine and rehabilitation services (excepting “supervised modality” services) even though they shall not be reported for the same fifteen-minute time period.”; “Physicians are expected to code correctly even in the absence of NCCI PTP edits.”; “The re-evaluation services shall not be routinely reported during a planned course of physical or occupational therapy.”; “Physical or occupational therapy services performed at the same patient encounter as cardiac rehabilitation or pulmonary rehabilitation services are included in the cardiac rehabilitation or pulmonary rehabilitation benefit and are not separately reportable.”; “If physical therapy or occupational therapy services are performed at a separate, medically reasonable and necessary patient encounter on the same date of service as cardiac rehabilitation or pulmonary rehabilitation services, both types of services may be reported using an NCCI PTP-associated modifier.”; “physical and occupational therapy services are not separately reportable with therapeutic pulmonary procedures (e.g., HCPCS codes G0237-G0239) for the same patient encounter.”.
9. Centers for Medicare & Medicaid Services. NCCI Policy Manual for Medicare Services, Chapter I, General Correct Coding Policies (effective January 1, 2026; revision date 1/1/2026; sections A, E and V). Checked October 25, 2026.
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   “NCCI PTP edits are applied to same-day services by the same provider/supplier to the same beneficiary”; “A modifier shall not be appended to a HCPCS/CPT code solely to bypass an NCCI PTP edit if the clinical circumstances do not justify its use.”; “A CCMI of “0” indicates that NCCI PTP-associated modifiers cannot be used to bypass the edit”; “A CCMI of “1” indicates that NCCI PTP-associated modifiers may be used to bypass an edit under appropriate circumstances.”; “This indicator is used for all code pairs that have a deletion date that is the same as the effective date.”; “Documentation in the medical record must satisfy the criteria required by any NCCI PTP-associated modifier used.”; “If 2 separate and distinct timed services are provided in separate and distinct time blocks, modifier 59 may be used to identify the services. The separate and distinct time blocks for the 2 services may be sequential to one another or split.”; “All Medicare rules for reporting timed services are applicable.”; “The practitioner is not permitted to perform multiple services, each for the minimal reportable time, and report each of these as separate UOS.”; “Additionally, different diagnoses are not adequate criteria for use of modifiers 59 or XE or XS.”; “Unusual Non-Overlapping Service, the use of a service that is distinct because it does not overlap usual components of the main service”; “MUEs for HCPCS codes with an MAI of “3” are “per day edits based on clinical benchmarks.””; “If contractors have evidence (e.g., medical review) that UOS in excess of the MUE value were actually provided, were correctly coded and were medically necessary, the contractor may bypass the MUE for a HCPCS code with an MAI of “3” during claim processing, reopening, or redetermination”.
10. Medicaid.gov. Early and Periodic Screening, Diagnostic, and Treatment (Centers for Medicare & Medicaid Services). Checked October 25, 2026.
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    “The Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit provides comprehensive and preventive health care services for children under age 21 who are enrolled in Medicaid.”; “States are required to provide any additional 1905(a) services that are coverable under the Federal Medicaid program and found to be medically necessary to treat, correct, or reduce illnesses and conditions discovered regardless of whether the service is covered in a state’s Medicaid plan.”; “It is the responsibility of states to determine medical necessity on a case-by-case basis.”.
11. American Occupational Therapy Association. 2026 Frequently Used CPT and HCPCS Codes for Occupational Therapy (coding list; code descriptors © 2026 American Medical Association). Checked October 25, 2026.
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    “The following CPT® and HCPCS G codes are frequently used by occupational therapy practitioners (OTPs) to report skilled services.”; “Not all codes are accepted by all payers.”; “Codes listed are effective as of January 1, 2026.”; the list includes 97110, 97112 and 97530, each reported in 15-minute units.
12. American Physical Therapy Association. Coding for Interventions (Current Procedural Terminology Codes) (Coding and Billing; public page). Checked October 25, 2026.
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    “However, PTs can bill any code if furnishing that service is permitted under state licensure laws and payer policy.”; “Keep in mind that CPT coding is not the same as payment policy.”; “all CPT codes and descriptions are copyrighted by AMA”.
13. Centers for Medicare & Medicaid Services. Annual Therapy Update (page last modified March 4, 2026, with the 2026 Therapy Code List and Dispositions workbook, CY_2026_Therapy_Code_List_and_Dispositions_v3.xlsx). Checked October 25, 2026.
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    “The files on this web page contain the list of codes indicating whether they are sometimes or always therapy services.”; “These codes are “always therapy” services, regardless of who performs them.”; “These HCPCS/CPT codes represent “sometimes therapy” services. However, these codes are “always therapy” services when furnished by a therapist”; in the workbook’s code list, 97110, 97112, 97116, 97140, 97150, 97530, 97533 and 97535 carry disposition 5 (always therapy) and 95992 carries disposition 7 (sometimes therapy), with no age limit stated for any of them.
14. Centers for Medicare & Medicaid Services. Jimmo Settlement (Important Message About the Jimmo Settlement; undated page). Checked October 25, 2026.
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    “Skilled therapy services are covered when an individualized assessment of the patient’s clinical condition demonstrates that the specialized judgment, knowledge, and skills of a qualified therapist (“skilled care”) are necessary for the performance of a safe and effective maintenance program.”; “does not turn on the presence or absence of a beneficiary’s potential for improvement, but rather on the beneficiary’s need for skilled care.”; “The Jimmo Settlement Agreement does not alter or supersede any other applicable coverage requirements beyond those involving the need for skilled care, such as Medicare’s overall requirement that covered services must be reasonable and necessary to diagnose or treat the beneficiary’s condition”.
15. American Physical Therapy Association. Coding for Timed Codes (Coding and Billing; public page, undated). Checked October 25, 2026.
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    “The CPT manual guidelines do not indicate a requirement to add total minutes to determine how many units can be billed, meaning a therapist could bill 1 unit of service every time the midpoint is passed for that unit of service.”; “It is critical to review payer policy to determine whether the payer follows the Medicare 8-minute rule or whether a provider may bill a unit every time the mid-point is passed.”.
16. American Physical Therapy Association. Medicare National Correct Coding Initiative (Coding and Billing; under the heading 2026 Updates). Checked October 25, 2026.
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    “On May 21, APTA submitted a formal request for deletion of the NCCI Procedure-to-Procedure edits associated with the following code pairs:”; “95992 with 97112; and 97150 with 97110, 97112, 97113, 97116, 97140, 97530”; “PTP edits - Practitioner are applied to claims submitted by physical therapists in private practice”; “PTP edits - Hospital are applied to claims submitted for services that are paid under the outpatient prospective payment system; for example, outpatient hospital services, Part B skilled nursing facilities, comprehensive outpatient rehabilitation facilities, outpatient physical therapy and speech-language pathology providers”; “In other words, these edits are no longer active, so the code combinations are billable, and no modifier is needed.”.
17. DrSensory. DrSensory for therapists (the For Therapists hub). “DrSensory is a directory families use free to find occupational therapy, physical therapy and speech therapy clinics”; “The directory lists clinics rather than individual therapists, so one listing covers a whole practice at one address.”. Checked October 25, 2026.
18. DrSensory. Therapy Clinic Directory Pricing (the pricing page). “Families never pay to search or to contact you.”; “We do not verify clinical quality.”; the comparison of free and paid listings marks “A description in your own words” and “Ages and conditions treated” as part of a paid listing. Checked October 25, 2026.

Medical disclaimer. This page is for general educational purposes and does not constitute medical advice, diagnosis, or treatment. It is general guidance on running a therapy practice, not legal, compliance, billing or financial advice. CPT is the American Medical Association’s code set; the code descriptions here are plain-language summaries, not the official descriptors.