Therapy modifiers: GP, GO, GN, KX, 59, CQ, CO

For OT, PT and SLP practice owners and billers treating children or adults: Medicare wants GP, GO or GN on every therapy line, KX past the 2026 threshold of $2,480, CQ or CO when an assistant furnishes over 10 percent of a service, and 59 or an X modifier only where an edit allows. Other payers set their own rules.⁠^1,2,3

What do the GP, GO and GN modifiers tell a payer?

They tell Medicare which discipline’s plan of care a service was delivered under: GP for physical therapy, GO for occupational therapy and GN for speech-language pathology. Chapter 5 of Medicare’s Claims Processing Manual requires one of the three on every line billed as therapy, whoever bills it, from therapists in private practice and physicians to hospitals and skilled nursing facilities.⁠¹ The modifier names the plan of care the service belongs to; it does not widen anyone’s scope, since the manual says the modifiers do not let a provider deliver a service Medicare does not recognize them to perform.⁠¹

Three rules follow from the same section. A line carries one discipline modifier, and Medicare’s contractors return institutional claims that report more than one on a line. Evaluation and re-evaluation codes always take their own discipline’s modifier, GP with a PT evaluation, GO with an OT evaluation and GN with a speech-language pathology evaluation. The modifiers never go on a code outside the therapy list; the manual’s examples are respiratory and nutrition therapy.⁠^1,4

The discipline modifiers are not Medicare’s alone. UnitedHealthcare’s commercial plans have required GN, GO or GP on the codes CMS designates as always therapy for dates of service since July 1, 2020, and Washington’s Medicaid program lists GP, GO and GN among the modifiers its billers must use.⁠^12,13 For every other plan, find the rule in its reimbursement policy or provider manual and keep a dated copy.

Which codes count as always therapy or sometimes therapy?

CMS’s yearly therapy code list decides: always-therapy codes, such as 97110, 97530, 92507 and the evaluation codes, are therapy services whoever performs them and always need GP, GO or GN, while sometimes-therapy codes, such as 92610, 96105 and 97129, become therapy services, and need the modifier, when a therapist furnishes them or when they are integral to a therapy plan of care.⁠⁴ When a sometimes-therapy code is not a therapy service, the therapy modifiers and threshold do not apply to it.⁠⁴ In the 2026 list, the codes therapy practices bill most often fall as follows.

Where one code could fall under two disciplines, the plan of care decides. Group therapy delivered under an OT plan of care carries GO, and the same code under a PT plan of care carries GP.⁠¹ The OT procedure codes guide and the speech therapy CPT codes guide map each discipline’s codes in full.

When does a therapy claim need the KX modifier in 2026?

When the patient’s therapy expenses for the year pass the KX threshold, which for 2026 is $2,480 for physical therapy and speech-language pathology combined and a separate $2,480 for occupational therapy.⁠² Section 50202 of the Bipartisan Budget Act of 2018 repealed the old therapy caps and kept their amounts as this threshold, indexed every year by the Medicare Economic Index, and claims above it without KX are denied.⁠^2,7,14

The amount belongs to the patient, not to the practice. Medicare counts the therapy services the patient receives, whoever provides them, applies the fee schedule amount or the charge if it is smaller, and applies the threshold in the order claims arrive; since 2018 it reaches every provider type the old limits did, outpatient hospitals among them.⁠⁵ So a patient who had physical therapy at a hospital outpatient department in the spring brings those dollars to a private practice’s speech-language pathology in the fall, because PT and SLP share one amount, while occupational therapy runs on its own.⁠^2,5

KX is an attestation, not a request. By adding it, the provider attests that the services are reasonable and necessary, need a therapist’s skills and are justified by documentation in the record, and the manual points to Benefit Policy Manual chapter 15, sections 220.2 and 220.3, for what those terms require; an inaccurate attestation exposes the provider to sanctions.⁠⁵ The same section bars KX on any line that is not medically necessary, calls KX abusive on professional claims when nothing suggests the threshold is likely to be passed, and on institutional claims puts it on every line under the same threshold once one line passes it.⁠⁵

A claim that needed KX and went without it loses the lines over the threshold, and the contractor may reopen or adjust it when the error is brought to its attention.⁠⁵ The loss falls on the practice: CMS’s therapy ABN guidance makes the therapist or provider liable when Medicare denies services over the threshold for a missing KX, and only a valid ABN moves liability to the patient.⁠^2,6 The patient’s side of the threshold is explained in the Medicare therapy coverage guide.

Is the $3,000 medical review threshold a cap on therapy?

No. Past $3,000 a year for PT and SLP combined, or for OT, Medicare’s targeted medical review may select claims for review, but not every claim over the amount is reviewed, and the practice keeps adding KX to reaffirm that the services are reasonable and necessary.⁠^2,6 The regulations set the review amount at $3,000 for each year before 2028 and, from 2028 on, raise it every year by the Medicare Economic Index.⁠^2,7 Medicare covers medically necessary therapy above both amounts, so neither is a reason to stop care that the record supports.⁠⁶

How do you track a patient’s spending toward the KX threshold?

Keep one running total per patient per year for each threshold, built from the allowed amounts on your own claims plus the therapy the patient reports from other providers, and mark the visit likely to cross it, so KX goes on the lines that may reasonably exceed the amount and not on earlier ones.⁠⁵ The plan of care, progress reports and notes that stand behind each KX line are the subject of the documentation audit guide. Read each year’s amounts from CMS’s Therapy Services page once CMS posts them, rather than carrying last year’s figures forward, since they are indexed every year.⁠²

When do the CQ and CO assistant modifiers apply?

CQ marks a physical therapy service and CO an occupational therapy service furnished in whole or in part by a physical therapist assistant or an occupational therapy assistant, and Medicare pays those lines at 85 percent of what it would otherwise pay.⁠^1,2 Section 53107 of the Bipartisan Budget Act of 2018 wrote the rule into the Social Security Act as section 1834(v): CMS had to create the modifiers by January 1, 2019, claims had to carry them from January 1, 2020, and the lower payment applies to services on or after January 1, 2022.⁠^2,15,16

CQ must sit beside GP and CO beside GO, or the claim is rejected as unprocessable, and the 15 percent reduction is taken last, after the multiple procedure payment reduction.⁠¹ On professional claims the modifiers apply to physical and occupational therapists in private practice, not to therapy billed by or incident to physicians or nonphysician practitioners; on institutional claims they apply to outpatient hospitals, rehabilitation agencies, skilled nursing facilities, home health agencies and comprehensive outpatient rehabilitation facilities, but not to critical access hospitals, which Medicare pays on cost.⁠¹

“In part” has a threshold, the de minimis standard. Minutes an assistant furnishes apart from the therapist that do not exceed 10 percent of a service, or of a unit, leave the line without the modifier, and minutes the assistant furnishes together with the therapist count as the therapist’s.⁠^2,7 CMS’s billing examples set the order of work:

• Full units first: each clinician’s full 15 minutes of a code earns a unit, and an assistant’s full unit always takes the modifier.⁠¹⁶
• The final unit: when the therapist furnished 8 or more minutes of the last unit, it bills without CQ or CO, whatever the assistant added.⁠^2,7
• Two units left of one code: when therapist and assistant each furnished 9 to 14 minutes of it and together 23 to 28, one unit takes the modifier and one does not.⁠²
• Different codes, one unit left: the code with more remaining minutes is billed, with the modifier only if those minutes were the assistant’s.⁠¹⁶
• Untimed codes: evaluations, re-evaluations, supervised modalities and group therapy bill one unit, and the 10 percent standard decides whether it carries the modifier.⁠¹⁶

These steps sit on Medicare’s unit table for timed codes, which the eight-minute rule guide works through with worked visits.

How do you test an assistant’s minutes against the de minimis rule?

Use either of CMS’s two methods on the minutes left after full units. The simple method adds the therapist’s and the assistant’s remaining minutes of the code, divides by 10, rounds to the nearest whole number and adds 1, giving the floor the assistant’s minutes must reach for the modifier; the percentage method divides the assistant’s remaining minutes by the total and applies the modifier at 11 percent or more.⁠¹⁶ In CMS’s group example, an OT and an OTA each lead 20 minutes of a group independently, the OTA’s share is half the time, and 97150 bills with CO for each member.⁠¹⁶

Is there an assistant modifier for speech-language pathology?

No. CQ and CO cover physical therapist assistants and occupational therapy assistants only, and Medicare’s Benefit Policy Manual says the services of speech-language pathology assistants are not recognized for Medicare coverage: even where a state licenses the assistant, the services are treated as unskilled and denied as not reasonable and necessary when billed as therapy.⁠^1,8 Aides’ services are not therapy services either, even under a therapist’s supervision.⁠⁸ For a Medicaid program or a commercial plan, get its written policy on assistants before a speech-language pathology assistant treats its members, and keep the copy.

When can modifier 59 or an X modifier bypass a therapy edit?

Only when the edit allows a modifier and the record shows the two services were truly separate. Medicare’s procedure-to-procedure edits apply to services the same provider furnishes the same patient on the same day: the column one code is eligible for payment, and the column two code is denied unless a clinically appropriate NCCI-associated modifier is reported.⁠^3,10 Each edit has an indicator: 1 lets such a modifier bypass it in the right circumstances, 0 means no modifier can, and 9 marks a pair whose deletion date equals its effective date.⁠³

For the NCCI program, the primary purpose of modifier 59 is to show that procedures were performed at different anatomic sites or at different patient encounters, and it is used only when no other modifier describes the relationship better.⁠³ Four more specific modifiers took effect January 1, 2015, and CMS asks for them instead of 59 whenever possible: XE for a separate encounter on the same date, XS for a separate organ or structure, XP for a different practitioner and XU for a service that does not overlap the usual components of the main one.⁠^3,9 CMS accepts these modifiers on either the column one or the column two code.⁠⁹

A modifier is never a way around an edit. NCCI forbids adding one solely to bypass an edit when the clinical circumstances do not justify it, requires the record to meet the criteria of any modifier used, and says different diagnoses are not adequate grounds for 59; CMS’s modifier booklet adds that two codes having different descriptions is not a reason either.⁠^3,9 The diagnosis codes on the claim follow their own rules, set out in the ICD-10-CM diagnosis coding guide.

For therapy, the case that matters is time. When the two codes of an edit are timed services furnished in separate blocks of time, sequential or split, a modifier may identify them, while Medicare’s timed-unit rules still apply to the total, and a clinician may not furnish several services for the minimum reportable time and bill each as a unit.⁠³ CMS’s documents name different modifiers for that case. The therapy chapter of the NCCI manual names 59 or XU for physical medicine pairs furnished in different timed intervals, while the modifier booklet names 59 or XE for timed services completed one after the other, and its own therapy example, manual therapy (97140) with a physical performance test (97750), uses 59 for distinct 15-minute blocks.⁠^9,10,17 Ask your Medicare contractor which it expects and file its answer with the date.

Which therapy code pairs have live edits in the October 2026 file?

In the Medicare practitioner file effective October 1, 2026, version 323r0, the common one-on-one pairs carry no live edit, while group therapy, speech treatment, device training, evaluations and re-evaluations do.⁠¹⁰ CMS changes the edit files every quarter, so read the current file before relying on any row; the table below reads this one for the pairs a therapy practice meets most.⁠¹⁰

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, and expects correct coding even where no edit exists.⁠¹⁷ When a patient has group and individual therapy on one day, Noridian, the Medicare contractor for Jurisdiction F, allows both when CPT and Medicare requirements are met, with the group’s untimed minutes kept apart from the individual timed minutes and 59 used as appropriate.⁠¹⁸ The 97110, 97112 or 97530 guide and the evaluation guides for PT and OT cover the coding behind these pairs.

When does XP fit a claim from a multidisciplinary clinic?

When two services on an edit came from different practitioners. The NCCI manual’s speech example fits a pediatric clinic with both disciplines: a single practitioner may not report 92507 or 92508 on the same day as 97129, 97130 or 97533, but when a speech-language pathologist furnishes the speech treatment and an occupational therapist the cognitive or sensory integrative service, an entity employing both may report both with an NCCI-associated modifier.⁠¹⁷ XP describes that case, a service distinct because a different practitioner performed it.⁠³ The same chapter lets a PT evaluation and an OT evaluation furnished by two practitioners on one day both be reported.⁠¹⁷

Which ABN modifiers apply to therapy: GA, GX, GY or GZ?

They record what an Original Medicare patient was told before a service Medicare may not pay for. The Advance Beneficiary Notice of Noncoverage, form CMS-R-131, goes to Original Medicare patients when payment is expected to be denied, to move potential financial liability to the patient; it must be delivered before the service, far enough ahead for a considered choice, reviewed with the patient and kept on file.⁠^19,20 The four modifiers report what happened:

• GA: a mandatory ABN was issued as required and is on file; you do not send it with the claim but must produce it on request.⁠¹¹
• GZ: you expect a denial as not reasonable and necessary and did not issue an ABN.⁠¹¹
• GX: a voluntary ABN was issued for a service Medicare never covers, because it is excluded by statute or is not a Medicare benefit.⁠¹¹
• GY: the service is excluded by statute or does not meet the definition of any Medicare benefit.⁠¹¹

In therapy the ABN turns on medical necessity, not on the year’s spending. CMS’s therapy ABN guidance requires a therapist who intends to collect from the patient to issue the ABN before therapy that is or may be denied as not reasonable and necessary, whatever the amount spent; therapy above the KX threshold that the therapist attests is medically necessary is covered, so no ABN can shift it to the patient, and KX and GA cannot share a line because they say opposite things.⁠⁶

CMS’s own example is a patient who has met every goal in the plan of care and asks to keep coming. The ABN goes out before the next visit. If the patient chooses option 1, the claim goes to Medicare with GA; option 2 means the patient pays and no claim is sent; option 3 means no service.⁠^6,20 A community wellness class Medicare never covers needs no ABN, though a voluntary one may be given.⁠⁶

For a patient with both Medicare and Medicaid, the form instructions require option 1, so the claim goes to Medicare, and forbid billing the patient until both programs have decided.⁠²⁰ The ABN is an Original Medicare form; for a Medicare Advantage member, read the plan’s provider manual for its own notice process.⁠¹⁹ Wording for money conversations with patients and families is in the payment explanation guide.

How do telehealth rules change therapy modifiers and place of service?

Under Medicare, a therapist’s telehealth claim is marked mainly by its place of service code, with new modifiers arriving in 2027, and the permission runs on a deadline: physical therapists, occupational therapists and speech-language pathologists may furnish Medicare telehealth through December 31, 2027, under section 6209 of the Consolidated Appropriations Act, 2026, and no longer from the start of 2028.⁠^4,21

• Professional claims: place of service 02 when the patient is not at home, 10 when the patient is at home.⁠^21,22
• Hospital outpatient therapy: modifier 95 on institutional claims for therapy a hospital-employed PT, OT or SLP furnishes by telehealth.⁠²²
• Critical access hospitals under the optional Method II: GT on institutional claims.⁠²²
• New for 2027: CMS lists BB, for telehealth through a virtual platform the practitioner contracts or pays for, and BC, for telehealth furnished incident to a professional service, as required from the first day of 2027, with no effect on payment.⁠²¹

Medicaid programs and commercial plans set their own telehealth rules. Washington’s Medicaid program pays for some PT, OT and speech therapy by audio-visual telemedicine under specific codes, and UnitedHealthcare’s commercial modifier policy refers 95 and GT to its telehealth policy.⁠^12,23 Read each plan’s telehealth policy before the first video visit, and record the place of service and modifiers it names.

Do Medicaid and commercial plans use the same therapy modifiers?

Some use the same discipline and assistant modifiers, but each payer writes its own list, and KX belongs to Medicare’s threshold.⁠² Washington’s Medicaid billing guide requires GP, GO and GN, requires CQ and CO paired with GP or GO, adds AF for audiology and specialty physician services, and rejects claims that do not pair the assistant modifier correctly.⁠¹² It counts each 15 minutes of a timed code as one unit.⁠¹²

Some programs mark habilitative care, the services that help a person attain or keep skills not fully acquired because of a congenital, genetic or early-acquired condition. Washington bills habilitative services for clients in its Alternative Benefit Plan under a separate guide, with an informational SZ modifier beside the standard ones.⁠^12,24 A commercial plan that counts habilitative and rehabilitative visits separately may want its own marker on the line, so ask each plan which modifiers it expects for each benefit and keep the answer with its date.

Medicaid has its own correct coding edits. CMS requires state Medicaid programs to apply NCCI methodologies to fee-for-service claims, leaves them optional for managed care organizations, and says the Medicaid edits differ from Medicare’s, some absent, some changed and some found only in Medicaid.⁠²⁵ Commercial plans apply edits too: UnitedHealthcare’s modifier reference lists 59, XE, XP, XS and XU among the modifiers its correct coding policy addresses.⁠²³ A Medicare pair with no live edit can still be edited by another payer, so check each payer’s own rules.

How do children’s Medicaid claims differ from adults’ Medicare claims?

The modifiers do not change with age; the payer, its threshold and its edits do. A child’s claim to a state Medicaid program follows that program’s modifier list and edit set, and Medicare’s KX threshold does not apply to it, while an adult’s Original Medicare claim carries GP, GO or GN, KX past the year’s threshold and CQ or CO as the minutes require.⁠^1,2,12 What Medicaid owes children is set out in the EPSDT guide, and joining a state program is covered in the Medicaid enrollment guide. For an adult in a Medicare Advantage plan, the plan’s manual decides whether it wants KX, the assistant modifiers and Medicare’s edits; ask before the first claim.

Which modifier applies, under which payer, and where is it written?

The table pairs each modifier with when it is required, the payers whose documents require it and the document that sets the rule; start from the situation on the claim line, and for any payer not named, look for the rule in that plan’s own policy.

How do you check the modifiers on each claim line before it goes?

Run every line through the same questions in the same order: discipline, threshold, assistant, edits, notices, setting. Medicare lets the modifiers appear in any order; the electronic professional claim holds four on a line, and a paper claim with more puts 99 in block 24D and the rest in block 19.⁠⁵

A denial that cites a pair of codes calls for the same check. Read the edit and its indicator in the file for the date of service, read the note, and add a modifier only when the record shows the separate time, encounter or practitioner; otherwise the column two line was correctly denied, and the fix is the coding, not the modifier.⁠^3,10

How would a child’s Medicaid claim and an adult’s Medicare claim look?

Line by line, as below: the child’s claim follows Washington’s Medicaid billing guide and the adult’s follows Medicare’s manuals and edit file.⁠^1,12 Both claims are hypothetical, and their minutes and amounts are inputs, not benchmarks.

Which modifier mistakes put therapy claims at risk?

The ones CMS’s manuals and edit files name directly. Check each claim line against this list before it goes:

• No discipline modifier, or two on one line: institutional claims go back to the provider.⁠¹
• GP, GO or GN on a code outside the therapy list: respiratory and nutrition therapy codes are the manual’s examples.⁠¹
• CQ without GP, or CO without GO: the claim is rejected as unprocessable.⁠¹
• Assistant minutes ignored: an assistant’s full unit always takes the modifier, and remaining minutes past the de minimis share do too.⁠¹⁶
• KX on every claim from the first visit: the manual calls it abusive when nothing suggests the threshold is likely to be passed.⁠⁵
• KX missing past the threshold: the lines are denied, and the provider bears the cost unless a valid ABN moved it.⁠^5,6
• KX on a service that is not medically necessary: barred; such a service takes an ABN and GA, and the two modifiers never share a line.⁠^5,6
• 59 by habit: a modifier added to get past an edit, or justified only by a different diagnosis or different code descriptions.⁠^3,9
• 59 where no edit exists: 97530 with 97140 has had no live edit since the end of 2019, so the modifier adds nothing, and overlapping minutes are barred either way.⁠^10,17
• Routine re-evaluations: NCCI says re-evaluations are not reported routinely during a planned course of PT or OT.⁠¹⁷
• SLPA or aide services billed as therapy: Medicare denies speech-language pathology assistants’ services as not reasonable and necessary, and aides’ services are not covered.⁠⁸

A monthly self-audit can stay small: pick a few claim lines per clinician, set each beside its note, its edit check and any ABN, and write down what matched, what did not and what the practice changed. When a billing service sends the claims, decide in writing who runs each of these checks; the billing service guide sets out how the steps divide.

Sources

1. Centers for Medicare & Medicaid Services. Medicare Claims Processing Manual, Chapter 5, Part B Outpatient Rehabilitation and CORF/OPT Services (Pub. 100-04; §20 B and C, Rev. 1850; §20.1, Discipline Specific Outpatient Rehabilitation Modifiers, Rev. 11129, effective January 1, 2022). Checked October 26, 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”; “GN Services delivered under an outpatient speech-language pathology plan of care”; “GO Services delivered under an outpatient occupational therapy plan of care”; “GP Services delivered under an outpatient physical therapy plan of care”; “This is applicable to all claims from physicians, nonphysician practitioners (NPPs), PTPPs, OTPPs, SLPPs, CORFs, OPTs, hospitals, SNFs, and any others billing for physical therapy, speech-language pathology or occupational therapy services”; “They should never be used with codes that are not on the list of applicable therapy services”; “For example, respiratory therapy services, or nutrition therapy services shall not be represented by therapy codes which require GN, GO, and GP modifiers”; “that no more than one GN, GO or GP modifier is reported on the same service line”; “that discipline-specific evaluation and re-evaluation HCPCS codes are always reported with the modifier for the associated discipline”; “Contractors return to the provider institutional claims that do not meet one or more of these conditions”; “CQ modifier: Outpatient physical therapy services furnished in whole or in part by a physical therapist assistant”; “CO modifier: Outpatient occupational therapy services furnished in whole or in part by an occupational therapy assistant”; “the CQ/CO modifiers apply only to services of physical and occupational therapists in private practice (PTPPs and OTPPs); and not to the therapy services furnished by or incident to the services of physicians or nonphysician practitioners (NPPs)”; “For providers submitting institutional claims and paid at PFS rates for their outpatient PT and OT services, the CQ and CO modifiers apply to the following providers: outpatient hospitals, rehabilitation agencies, skilled nursing facilities, home health agencies and CORFs”; “the CQ and CO modifiers are not applicable to claims from critical access hospitals because they are paid on a reasonable cost basis”; “The CQ modifier must be paired to the GP therapy modifier and the CO modifier with the GO therapy modifier. Claims not so paired will be rejected/returned as unprocessable”; “The 15 percent reduction is taken last, e.g., after the MPPR (and other reductions where applicable) and right before sequestration”.
2. Centers for Medicare & Medicaid Services. Therapy Services (page last modified March 10, 2026; section Implementation of the Bipartisan Budget Act of 2018, last revised February 2026). Checked October 26, 2026.
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   “Section 50202 of the BBA of 2018 repeals application of the Medicare outpatient therapy caps and its exceptions process”; “the law preserves the former therapy cap amounts as thresholds above which claims must include the KX modifier as a confirmation that services are medically necessary as justified by appropriate documentation in the medical record”; “there is one amount for PT and SLP services combined and a separate amount for OT services. This amount is indexed annually by the Medicare Economic Index (MEI)”; “Claims for services over the KX modifier threshold amounts without the KX modifier are denied”; “$2,480 for PT and SLP services combined, and”; “$2,480 for OT services”; “For CY 2021 (and each calendar year until 2028 at which time it is indexed annually by the MEI), the MR threshold is $3,000 for PT and SLP services and $3,000 for OT services. The targeted MR process means that not all claims exceeding the MR threshold amount are subject to review as they once were”; “continues to provide limitation of liability protections to beneficiaries receiving outpatient therapy services when services are denied for certain reasons, including failure to include a necessary KX modifier”; “Payment for these services is at 85 percent of the otherwise applicable PFS payment amount/rate for the service, effective January 1, 2022”; “(a) establish a new modifier to identify services furnished in whole or in part by a PTA or OTA by January 1, 2019 and (b) require the modifier on claims beginning January 1, 2020”; “CQ modifier: PT services furnished in whole or in part by PTAs and”; “CO modifier: OT services furnished in whole or in part by OTAs”; “portions of a service furnished by the PTA/OTA independent of the physical therapist/ occupational therapist (PT/OT), as applicable, that do not exceed 10 percent of the total service are not subject to the payment reduction”; “Portions of services provided by the PTA/OTA together with the PT/OT are counted as services provided by the PT or OT”; “In cases where there is one final 15-minute unit left to bill, the ‘8-minute rule’ rule is applied when the PT/OT furnishes 8 or more minutes”; “that final unit is billed without the CQ/CO modifier because the PT/OT provided enough minutes on their own (more than half) to report the service”; “When there are two units of the same service remaining to be billed, and the PT/OT and the PTA/OTA each furnish between 9 and 14 minutes of a 15-minute timed service where the total time of therapy services furnished in combination by the PTA/OTA and PT/OT is at least 23 but no more than 28 minutes, one unit of the service is billed with the CQ/CO modifier (for the unit furnished by the PTA/OTA) and one unit is billed without it (for the unit furnished by the PT/OT)”; “Medicare applies a MPPR to the practice expense component of certain ‘always therapy’ services. Since April 1, 2013, the MPPR rate is 50 percent for both practitioner/office and institutional settings”.
3. Centers for Medicare & Medicaid Services. NCCI Policy Manual for Medicare Services, Chapter I, General Correct Coding Policies (revision date January 1, 2026; section E, Modifiers and Modifier Indicators). Checked October 26, 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. A CCMI of ‘9’ indicates that the use of NCCI PTP-associated modifiers is not specified. This indicator is used for all code pairs that have a deletion date that is the same as the effective date”; “For the NCCI program, its primary purpose is to indicate that 2 or more procedures are performed at different anatomic sites or different patient encounters”; “Modifier 59 shall only be used if no other modifier more appropriately describes the relationships of the 2 or more procedure codes”; “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”; “The practitioner is not permitted to perform multiple services, each for the minimal reportable time, and report each of these as separate UOS”; “different diagnoses are not adequate criteria for use of modifiers 59 or XE or XS”; “Modifiers XE, XS, XP, XU: These modifiers were effective January 1, 2015”; “may be used in lieu of modifier 59 whenever possible”; “XE – ‘Separate Encounter, A service that is distinct because it occurred during a separate encounter.’ This modifier shall only be used to describe separate encounters on the same date of service”; “XS – ‘Separate Structure, A service that is distinct because it was performed on a separate organ/structure’”; “XP – ‘Separate Practitioner, A service that is distinct because it was performed by a different practitioner’”; “XU – ‘Unusual Non-Overlapping Service, the use of a service that is distinct because it does not overlap usual components of the main service’”.
4. 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 26, 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 codes always require a therapy modifier”; “These HCPCS/CPT codes represent ‘sometimes therapy’ services. However, these codes are ‘always therapy’ services when furnished by a therapist and in this situation require the use of a therapy modifier”; “When these ‘sometimes therapy’ codes are not considered therapy services, the therapy thresholds and therapy modifiers do not apply”; “these codes always represent therapy services when rendered by therapists or by practitioners who are not therapists in situations where the service provided is integral to an outpatient rehabilitation therapy plan of care”; “These evauluation and re-evaluation codes require a specific therapy modifier”; “face-to-face with the caregiver without the patient present”; “have continued to be available to PTs, OTs, and SLPs through a series of extensions as telehealth services they can now furnish through December 31, 2027 (via section 6209 of the Consolidated Appropriations Act, 2026)” ; in the workbook’s code list, 92507, 92508, 92526, 96125, 97110, 97112, 97116, 97140, 97150, 97530, 97533, 97535, 97750, 97755 and 97763 carry disposition 5 (always therapy); 92521 to 92524 carry dispositions 5 and 9 with GN, 97161 to 97164 dispositions 5 and 9 with GP, and 97165 to 97168 dispositions 5 and 9 with GO; 92610, 95992, 96105, 97129 and 97130 carry disposition 7 (sometimes therapy), and 97550 to 97552 dispositions 7 and 11.
5. Centers for Medicare & Medicaid Services. Medicare Claims Processing Manual, Chapter 5, Part B Outpatient Rehabilitation and CORF/OPT Services (Pub. 100-04; §10.2 C, §10.3 and §10.3.3, Rev. 4214, effective January 1, 2019; §10.3.4). Checked October 26, 2026.
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   “retains the former cap amounts as a threshold of incurred expenses above which claims must include a modifier as a confirmation that services are medically necessary as justified by appropriate documentation in the medical record. This is termed the KX modifier threshold”; “The limitation is based on therapy services the Medicare beneficiary receives, not the type of practitioner who provides the service”; “Contractors apply the financial limitations or thresholds to the MPFS amount (or the amount charged if it is smaller) for therapy services for each beneficiary”; “Medicare shall apply these financial limitations or KX modifier thresholds in order, according to the dates when the claims were received”; “the limits also apply to outpatient Part B therapy services furnished in outpatient hospitals other than CAHs and hospitals in Maryland”; “Effective for dates of service on or after January 1, 2018, the KX modifier threshold applies to all the therapy provider types to which the limits applied”; “It no longer represents an exception request but serves as a confirmation that services are medically necessary after the beneficiary has exceeded the KX modifier threshold of incurred expenses”; “The KX modifier shall not be added to any line of service that is not a medically necessary service”; “In addition to the KX modifier, the GN, GP and GO modifiers shall continue to be used. Providers may report the modifiers on claims in any order”; “if the provider has more than four to report, he/she can do so by placing the -99 modifier (which indicates multiple modifiers) in block 24D and placing the additional modifiers in block 19”; “The 837 professional transaction currently permits the placement of up to four modifiers”; “it is only appropriate to append the KX modifier to a service that reasonably may exceed the cap. Use of the KX modifier when there is no indication that the cap is likely to be exceeded is abusive”; “use the KX modifier on all of the lines on that institutional claim that refer to the same therapy cap (PT/SLP or OT), regardless of whether the other services exceed the cap”; “Are reasonable and necessary services that require the skills of a therapist; (See Pub. 100-02, chapter 15, section 220.2)”; “Are justified by appropriate documentation in the medical record, (See Pub. 100-02, chapter 15, section 220.3)”; “If this attestation is determined to be inaccurate, the provider/supplier is subject to sanctions resulting from providing inaccurate information on a claim”; “Providers and suppliers shall continue to append correct coding initiative (CCI) HCPCS modifiers under current instructions”; “In cases where appending the KX modifier would have been appropriate, contractors may reopen and/or adjust the claim, if it is brought to their attention”.
6. Centers for Medicare & Medicaid Services. Outpatient Therapy Services and Advance Beneficiary Notice of Noncoverage (ABN), Form CMS-R-131 (frequently asked questions, August 2018, linked from the Therapy Services page). Checked October 26, 2026.
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   “the therapist or therapy provider is financially liable for the cost of therapy services provided to a beneficiary above the threshold amount when Medicare denies payment for failure to use the −KX modifier to indicate that the services are medically necessary as justified by documentation in the medical record. In order for the therapist or therapy provider to transfer liability to the beneficiary, s/he must issue a valid ABN, Form CMS-R-131”; “Therapists and therapy providers that intend to collect from beneficiaries directly are required to issue the ABN to original (fee-for–service) Medicare beneficiaries prior to providing therapy that is or may be denied as not medically reasonable and necessary regardless of the amount of incurred expenses”; “he has achieved all his PT goals established in the plan of care (POC)”; “If the beneficiary selects option 1 on the ABN, the claim must be submitted to Medicare for review. The −GA modifier would be used on the claim”; “If the beneficiary selects option 2, s/he agrees to pay for the services and no claim is submitted”; “If the beneficiary selects option 3, s/he agrees to not receive the services and therefore, no claim”; “The –KX and –GA modifiers cannot be added to the same claim line of service because they convey opposing payer policy”; “A4: No, Medicare covers therapy services above the −KX modifier thresholds for which the therapist or therapy provider attests are medically reasonable and necessary”; “the therapist or therapy provider would continue to apply the −KX modifier to the claim to reaffirm that the services are medically reasonable and necessary”; “An ABN is not needed for services that Medicare would never cover. If desired, a voluntary ABN can be issued to the patient”.
7. 42 CFR. §410.60, Outpatient physical therapy services: Conditions (text as published in the eCFR, issue of October 22, 2026; paragraphs (a)(4) and (e)(1)(v)). Checked October 26, 2026.
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   “Claims for services furnished in whole or in part by a physical therapist assistant must include the prescribed modifier”; “claims for such services that include the modifier and for which payment is made under sections 1848 or 1834(k) of the Act are paid an amount equal to 85 percent of the amount of payment otherwise applicable for the service”; “such that the minutes for that portion of a service (or unit of a service) furnished by the physical therapist assistant exceed 10 percent of the total minutes for that service (or unit of a service)”; “does not apply when determining whether the prescribed modifier applies to the last 15-minute unit of a service billed for a patient on a treatment day, when the physical therapist provides more than the midpoint of a 15-minute timed code, that is, 8 or more minutes, regardless of any minutes for the same service furnished by the physical therapist assistant”; “is instead applied as a threshold above which claims for physical therapy and speech-language pathology services must include the KX modifier (the KX modifier threshold) to indicate that the service is medically necessary and justified by appropriate documentation in the medical record; and claims for services above the KX modifier threshold that do not include the KX modifier are denied”; “Beginning with 2018 and before 2028, $3,000”; “For 2028 and each year thereafter, the applicable medical review threshold is determined by increasing the medical review threshold in effect for the previous year (starting with $3,000 for 2017) by the increase in the Medicare Economic Index for the current year”.
8. 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; §230.3 C, Services of Speech-Language Pathology Support Personnel). Checked October 26, 2026.
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   “Services of speech-language pathology assistants are not recognized for Medicare coverage. Services provided by speech-language pathology assistants, even if they are licensed to provide services in their states,”; “considered unskilled services and denied as not reasonable and necessary if they are billed as therapy services”; “Services provided by aides, even if under the supervision of a therapist, are not therapy services and are not covered by Medicare”.
9. Centers for Medicare & Medicaid Services. Proper Use of Modifiers 59, XE, XP, XS & XU (Medicare Learning Network booklet MLN1783722, April 2026). Checked October 26, 2026.
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   “CPT codes, descriptions, and other data only are copyright 2025 American Medical Association. All Rights Reserved”; “Use modifier 59 only when no other modifier better describes the relationship between the procedure codes”; “Modifiers XE, XP, XS, and XU are valid modifiers. These modifiers give greater reporting specificity in situations where you used modifier 59 previously. Use these modifiers instead of modifier 59 whenever possible”; “We allow modifiers 59, XE, XP, XS, or XU on Column 1 or Column 2 codes”; “If you provide 2 timed services in separate and distinct time periods that aren’t mingled with each other (in other words, you complete 1 service before the next service begins), you may use modifier 59 or XE to identify the services”; “Don’t use modifier 59 or XU just because the code descriptors of the 2 codes are different”; “different diagnoses aren’t adequate criteria for using modifiers 59, XE, XP, XS, or XU”; “You may report modifier 59 if you perform 2 procedures in distinctly different 15-minute time blocks”; “you may report modifier 59 if you split the therapy time blocks by performing manual therapy for 10 minutes, followed by 15 minutes of physical performance test, followed by another 5 minutes of manual therapy”.
10. Centers for Medicare & Medicaid Services. Medicare NCCI Procedure to Procedure (PTP) Edits (page last modified September 1, 2026; 2026 Quarter 4 practitioner file, version 323r0, part 4, read in full for therapy and speech codes). Checked October 26, 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, 0 not allowed and 1 allowed), the live rows (no deletion date) among therapy and speech codes include: 97150 over 97110, 97112, 97116, 97140, 97530, 97533 and 97535, indicator 1; 92507 over 97110, 97112, 97129, 97150, 97530 and 97533, indicator 1; 92508 over 92507, indicator 1; 92526 over 97110, 97112, 97150 and 97530, indicator 1, and over 97032 and G0283, indicator 0; 97012 over 97140, indicator 1; 97140 over 97124, indicator 0, and over 97750, indicator 1; 97760, 97761 and 97763 each over 97110, 97112, 97116 and 97140, indicator 1; 97755 over 97110, 97112, 97140, 97530, 97533 and 97535, indicator 1; 97533, 97535, 97129, 97130, 97760, 97761, G0283 and the modalities 97012 to 97036 each over 97164 and 97168, indicator 1; each of 97161 to 97168 over 97750, 97755 and 97763, indicator 0; 97161, 97162 and 97163 over 97164, and 97165, 97166 and 97167 over 97168, indicator 0; 92523 over 92522, indicator 0; 92521 to 92524 and 97161 to 97168 each over 96105 and 96125, indicator 1; no live row pairs 97530 with 97140 (the row 97140/97530 carries a deletion date of December 31, 2019), none pairs 97110 or 97112 with 97140 (their rows carry indicator 9 with the deletion date equal to the effective date), none pairs any of 97161 to 97163 or 97165 to 97167 with 97110, 97112, 97140 or 97530, the rows pairing 97110, 97112, 97116, 97140, 97150 and 97530 over 97164 and 97168 carry indicator 9 with deletion dates equal to their effective date of October 1, 2020, and no row pairs 92507 with 92526 or with 92521 to 92524.
11. Centers for Medicare & Medicaid Services. Medicare Advance Written Notices of Non-coverage (Medicare Learning Network booklet MLN006266, May 2025; Table 2, Using Modifiers for ABN Claim Reporting). Checked October 26, 2026.
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    “Report when you issue a mandatory ABN for a service as required and keep it on file. You don’t need to submit a copy of the ABN, but you must make it available upon request”; “Report when you issue a voluntary ABN for a service we never cover because it’s statutorily excluded or isn’t a Medicare benefit”; “Report when Medicare statutorily excludes the item or service, or the item or service doesn’t meet the definition of a Medicare benefit”; “Report when you expect we’ll deny payment for the item or service because it’s not medically necessary and you didn’t issue an ABN”.
12. Washington State Health Care Authority. Washington Apple Health (Medicaid) Outpatient Rehabilitation Billing Guide (July 10, 2026; Are modifiers required for billing?, and the Coverage Table). Checked October 26, 2026.
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    “Each 15 minutes of a timed CPT® code equals one unit”; “Habilitative services are those medically necessary services provided to help a client partially or fully attain or maintain developmental age-appropriate skills that were not fully acquired due to a congenital, genetic, or early-acquired health condition”; “Yes. Providers must use the appropriate modifier when billing the Health Care Authority”; “The CQ or CO modifier must be included on the claim line of the service along with the appropriate GP or GO therapy modifier”; “Claims that do not reflect this combination will be rejected/returned as unprocessed”; “HCA pays for telehealth services for PT, OT, or ST when provided via audio-visual telemedicine and billed with specific procedure codes if clinically appropriate as determined by the practitioner, per standard of care” ; its modifier table lists GP for physical therapy, CQ for a physical therapy assistant, GO for occupational therapy, CO for an occupational therapy assistant, GN for speech therapy and AF for audiology and specialty physician, and its Coverage Table key adds TS for a follow-up service and RT and LT for right and left.
13. UnitedHealthcare. Procedure to Modifier Policy, Professional (Commercial and Individual Exchange reimbursement policy 2026R0119A; history entry May 1, 2026). “Effective with dates of service on or after July 1, 2020, UnitedHealthcare aligns with CMS and requires HCPCS modifiers GN, GO or GP to be reported with the codes designated by CMS as always therapy services”. Checked October 26, 2026.
14. 42 CFR. §410.59, Outpatient occupational therapy services: Conditions (text as published in the eCFR, issue of October 22, 2026; paragraphs (a)(4) and (e)(1)(v)). Checked October 26, 2026.
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    “Claims for services furnished in whole or in part by an occupational therapy assistant must include the prescribed modifier”; “are paid an amount equal to 85 percent of the amount of payment otherwise applicable for the service”; “is instead applied as a threshold above which claims for occupational therapy services must include the KX modifier (the KX modifier threshold) to indicate that the service is medically necessary and justified by appropriate documentation in the medical record and claims for services above the KX modifier threshold that do not include the KX modifier are denied”.
15. Legal Information Institute, Cornell Law School. 42 U.S. Code §1395m (Social Security Act §1834) (subsection (v), Payment for outpatient physical therapy services and outpatient occupational therapy services furnished by a therapy assistant). Checked October 26, 2026.
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    “that is furnished in whole or in part by a therapy assistant (as defined by the Secretary) , the amount of payment for such service shall be an amount equal to 85 percent of the amount of payment otherwise applicable for the service under this part”; “shall include the modifier established under subparagraph (A) for each such service”.
16. Centers for Medicare & Medicaid Services. Billing Examples Using CQ/CO Modifiers for Services Furnished In Whole or In Part by PTAs and OTAs (page last modified February 26, 2026; General Policy Rules and Examples A to H). Checked October 26, 2026.
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    “Section 53107 of the Bipartisan Budget Act (BBA of 2018) added a new section 1834(v) of the Social Security Act”; “When a PT, PTA, OT, or OTA provides at least 15 minutes and less than 30 minutes of a service on a single treatment day, assign 1 unit”; “When any of these services, i.e., full 15 minute increments, are provided by PTAs/OTAs, the CQ/CO modifiers apply”; “Simple Method : For instances where the de minimis is applicable, once Step 1 is applied for each service (if applicable), where there are remaining minutes for the same service provided by the PTA/OTA and the PT/OT, add these together, divide that total by 10, then round to the nearest integer to get the 10 percent de minimis standard for that service. Then, add 1 minute to get the PTA/OTA minute floor. The CQ/CO modifier applies when the PTA/OTA minutes meet or exceed this floor number”; “Percentage Method : After Step 1 is applied, determine if there are remaining minutes provided by the PTA/OTA and the PT/OT for the same service. If so, divide the remaining PTA/OTA time by the total time (PTA/OTA minutes + PT/OT minutes for the same service). Then multiply by 100 to get the percentage and round to the nearest integer. Where this number is greater than 10 percent (11 percent or more), the CQ/CO modifier applies”; “Bill for the service that took the most time. That is, assign the CQ/CO modifier to the service provided by the PTA/OTA when the time he/she spent is greater than the time spent by the PT/OT performing the different service”; “The de minimis policy is applicable when the PT and the PTA or the OT and the OTA each independently provide minutes of the same untimed service, including: supervised modalities, evaluations and re-evaluations, group therapy, and certain RTM codes”; “One unit of group therapy 97150 is billed with the CO modifier because the OTA provided more than the 10 percent time standard in this example”; “Bill 1 unit of 97110 with the CQ modifier because the PTA provided a full 15-minute unit, and bill 2 units of 97110 without the CQ modifier”.
17. Centers for Medicare & Medicaid Services. NCCI Policy Manual for Medicare Services, Chapter XI, Medicine and Evaluation and Management Services (revision date January 1, 2026; sections H.2, H.3, P.1 to P.3 and P.8). Checked October 26, 2026.
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    “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”; “A single practitioner shall not report CPT codes 92507”; “if the 2 types of services are performed by different types of practitioners on the same date of service, they may be reported separately by a single billing entity”; “a provider entity that employs both types of practitioners may report both services using an NCCI PTP-associated modifier”; “An occupational therapist may report only one evaluation/re-evaluation (CPT codes 97165-97168) on a single date of service. A physical therapist may report only one evaluation/re-evaluation (CPT codes 97161-97164) on a single date of service”; “If the 2 services are performed by 2 different practitioners on the same date of service, both procedures may be reported”; “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”; “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. However, if the patient’s status should change and a re-evaluation is medically reasonable and necessary, it may be reported with modifier 59 or XU appended to CPT code 97164 or 97168 as appropriate”; “are not separately reportable for the same date of service with a physical therapy evaluation/re-evaluation CPT code (e.g., 97161-97164) or occupational therapy evaluation/re-evaluation CPT code (e.g., 97165-97168) when the 2 services are performed by a single practitioner or 2 practitioners of the same specialty”.
18. Noridian Healthcare Solutions, Medicare Administrative Contractor for Jurisdiction F Part B (Alaska, Arizona, Idaho, Montana, North Dakota, Oregon, South Dakota, Utah, Washington, Wyoming). Rehabilitation Delivery Methods (JF Part B billing article, last updated July 11, 2025). Checked October 26, 2026.
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    “When both Current Procedural Terminology (CPT) and Medicare requirements are met, for individual and group therapy services provided to the same patient on the same day, then both services may be billed”; “Documentation must clearly distinguish the group therapy activity/untimed minutes from the individual therapy activity/time-based minutes. Modifier 59 may be used as appropriate when all requirements are met”.
19. Centers for Medicare & Medicaid Services. FFS ABN (Beneficiary Notices Initiative page, last modified July 17, 2026). Checked October 26, 2026.
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    “The Advance Beneficiary Notice of Noncoverage (ABN), Form CMS-R-131, is issued by providers (including independent laboratories, home health agencies, and hospices), physicians, practitioners, and suppliers to Original Medicare (fee for service - FFS) beneficiaries in situations where Medicare payment is expected to be denied”; “The ABN is issued in order to transfer potential financial liability to the Medicare beneficiary in certain instances”.
20. Centers for Medicare & Medicaid Services. Form Instructions, Advance Beneficiary Notice of Non-coverage (ABN) (OMB Approval Number 0938-0566). Checked October 26, 2026.
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    “Deliver the ABN to the patient or their representative before providing the items or services”; “Review the ABN with the patient or their representative and answer any questions before it’s signed”; “Deliver the ABN far enough in advance that the patient or representative has time to consider the options and make an informed choice”; “Retain a copy of the completed, signed ABN on file”; “The ABN may also be used to notify patients of their financial liability for items or services that Medicare never covers”; “Dually eligible patients must be instructed to check Option Box 1 on the ABN for a claim to be submitted for Medicare adjudication”; “Providers must not bill the patient until adjudication by both Medicare and Medicaid”.
21. Centers for Medicare & Medicaid Services. Telehealth FAQ (updated October 8, 2026). Checked October 26, 2026.
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    “Starting January 1, 2028, physical therapists, occupational therapists, speech-language pathologists, and audiologists can no longer furnish Medicare Telehealth services”; “Physicians and/or practitioners should use POS 02 for Telehealth Provided Other than in Patient’s Home or POS 10 for Telehealth Provided in Patient’s Home”; “are required beginning January 1, 2027”; “No, these modifiers do not have payment implications” ; question 17 names the modifiers BB, for telehealth furnished through a virtual platform owned by an entity the practitioner contracts or has a payment arrangement with, and BC, for telehealth furnished incident to a physician’s or practitioner’s professional service.
22. Centers for Medicare & Medicaid Services. Telehealth & Remote Monitoring (Medicare Learning Network booklet MLN901705, December 2025; Place of Service Codes). Checked October 26, 2026.
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    “Use modifier 95 for outpatient therapy services provided via telehealth by qualified physical therapists, occupational therapists, or speech language pathologists employed by hospitals”; “Distant site practitioners billing telehealth under the CAH optional payment Method II must submit institutional claims using the GT modifier”.
23. UnitedHealthcare. Modifier Reference Policy, Professional (Commercial and Individual Exchange reimbursement policy 2026R0111B; history entry March 6, 2026). Checked October 26, 2026.
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    “CCI Editing 24, 25, 57, 58, 59, 78, 79, 91, E1, E2, E3, E4, LC, LD, LM, LT” ; its reference table lists XE, XP, XS and XU as HCPCS modifiers for subsets of distinct procedural services, each addressed by its CCI Editing policy, and refers modifiers 95 and GT to its Telehealth/Virtual Health policy.
24. Washington State Health Care Authority. Washington Apple Health (Medicaid) Habilitative Services Program Billing Guide (January 1, 2026). “Eligibility for habilitative services is limited to clients who are enrolled in the Alternative Benefit Plan (ABP)”; “In addition to standard billing modifiers, use the informational SZ modifier to identify habilitative services”. Checked October 26, 2026.
25. Centers for Medicare & Medicaid Services. NCCI for Medicaid (page last modified March 4, 2026). Checked October 26, 2026.
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    “The Medicaid NCCI methodologies must be applied to Medicaid fee-for-service (FFS) claims which are submitted with and reimbursed on the basis of Healthcare Common Procedure Coding System (HCPCS) and Current Procedural Terminology (CPT) codes”; “Application of NCCI methodologies to FFS claims processed by limited benefit plans or Managed Care Organizations (MCOs) is desirable but optional. The Medicaid NCCI program has significant differences from the Medicare NCCI program”; “Some Medicare NCCI edits are not present in the Medicaid NCCI program, while others are present but differ in some way from the Medicare NCCI edits”; “The Medicaid NCCI program has certain edits unique to the Medicaid NCCI program”.
26. 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”; “DrSensory does not verify clinical quality”. Checked October 26, 2026.
27. DrSensory. Therapy Clinic Directory Pricing (the pricing page). “Families never pay to search or to contact you”; “A description in your own words”; “Share your approach, services, and what families can expect”; “Ages and conditions treated”. Checked October 26, 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, and the claims in the worked examples are hypothetical.