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The analysis of any legal or medical billing is dependent on numerous specific facts — including the factual situations present related to the patients, the practice, the professionals and the medical services and advice. Additionally, laws and regulations and insurance and payer policies are subject to change. The information that has been accurate previously can be particularly dependent on changes in time or circumstances. The information contained in this web site is intended as general information only. It is not intended to serve as medical, health, legal or financial advice or as a substitute for professional advice of a medical coding professional, healthcare consultant, physician or medical professional, legal counsel, accountant or financial advisor. If you have a question about a specific matter, you should contact a professional advisor directly. CPT copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

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  • Updated NCCI Codes for Therapy Services - January 2026

    1 Jan 2026 11:59 AM | Zachary Edgar (Administrator)

    See all the therapy codes at: https://therapycomply.com/NCCI/


  • Medicare 2026 Payment Updates

    5 Nov 2025 12:08 PM | Zachary Edgar (Administrator)

    Overall potential 4% cut without changes by January 30, 2026.

    The 2026 MPFS includes modest payment updates but continues to place downward pressure on speech-language pathology reimbursement. Although Congress approved a one-time 2.5% payment increase for 2026, these gains may be offset by new Centers for Medicare & Medicaid Services (CMS) policies and mandatory federal budget reductions, resulting in potential overall cuts of approximately 4% without additional legislative intervention.

    Congress establishes annual payment updates to the MPFS, which were frozen at 0.0% from 2020 through 2025 because of a provision in the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015.

    Beginning in 2026, MACRA put in place a variable annual update dependent on participation in Advanced Alternative Payment Models (APMs). Those clinicians participating in APMs will receive an annual update of 0.75%. All other clinicians are eligible for a 0.25% annual update. The One Big Beautiful Bill Act (OBBBA) also provided a one-time positive payment update of 2.5% for 2026. Additional payment adjustments—based on legislative and regulatory actions, or participation in the MIPS or APMs—may also apply.  

    Significant payment cuts to all services provided under the MPFS will continue in 2026. These cuts have gone into effect each year since 2021 due to changes in payment for outpatient office-based evaluation and management (E/M) services and adjustments to the annual conversion factor.

    Conversion Factor (CF)

    CMS uses the CF to calculate MPFS payment rates. Beginning 2026, there will be two separate CFs: 1. $33.57 for clinicians who participate in a qualified APM, representing a 3.8% increase from the 2025 CF. 2. $33.40 for clinicians who do not participate in a qualified APM, representing a 3.3% increase from the 2025 CF.

    Most therapists do not participate in a qualifying APM and will use the $33.40 CF to calculate payment rates. These CFs reflect the combined increases mandated in MACRA and OBBBA (explained in more detail above) but fail to account for reductions that will be applied due to a variety of policy changes such as the efficiency adjustment imposed by CMS and elimination of the geographic practice cost index (GPCI) floor, which will reduce payment to specific localities beginning January 31, 2026. In some instances, these reductions eliminate and further reduce the legislative increases provided by Congress.

    Efficiency Adjustment

    For 2026, the efficiency adjustment will be -2.5 percent.

    Full list of codes subject to the efficiency adjustment 

    Malpractice (MP) RVUs and Geographic Practice Cost Indices (GPCIs)

    CMS updates both MP RVUs and GPCIs every three years to ensure that payments remain aligned with current cost and risk data. The next update will take effect in CY 2026 and will impact payment rates for therapy services.

    MP RVUs represent the portion of a CPT code’s total RVU that accounts for professional liability insurance costs associated with a service. These values are based on the relative risk of malpractice claims across different medical specialties. While most MP values for speech-language pathology services did not change, CMS has finalized additional reductions to MP values for certain codes and did not provide significant increases to MP values. GPCIs adjust Medicare payments to reflect differences in the cost of care across various regions of the country.

    There are three separate GPCIs corresponding to the three RVU components:

    • •        Work GPCI, which adjusts for geographic differences in clinical labor costs;
    • •        Practice Expense GPCI, which accounts for regional variation in overhead costs such as rent, staff wages, and supplies; and
    • •        Malpractice GPCI, which reflects differences in malpractice insurance premiums among geographic areas.

    A nationwide 1.0 floor for the work GPCI was temporarily extended through January 30, 2026. Congress will need to once again extend the floor or make it permanent. Otherwise, geographic localities previously benefiting from it may see reductions in work GPCI-related payments in CY 2026.

    Multiple Procedure Payment Reductions (MPPR)

    The MPPR policy for therapy services will continue in 2026. Under this system, per-code payment is decreased when multiple therapy services are performed for a single beneficiary on the same day. This per-day policy applies to services provided by all therapy disciplines (i.e., speech-language pathology, physical therapy, and occupational therapy) in the same facility.

    Therapy Threshold

    The therapy threshold increases by 1.7 percent.

    $2,480 for physical therapy and speech-language pathology services combined, and $2,480 for occupational therapy services. The threshold for targeted medical review remains $3,000 for combined physical therapy and speech-language pathology services, and $3,000 for occupational therapy services.

    Telehealth

    In addition, the CMS finalized permanent telehealth coverage for speech-language pathology codes— though congressional action has only extended coverage for therapists through January 30, 2026.

    Remote Therapeutic Monitoring

    Four new remote therapeutic monitoring (RTM) codes have been added for 2026, although one code, 98986, is specifically designated for cognitive behavioral therapy.

    • 98984: Remote therapeutic monitoring (eg, therapy adherence, therapy response, digital therapeutic intervention); device(s) supply for data access or data transmissions to support monitoring of respiratory system, 2-15 days in a 30-day period
    • 98985:Remote therapeutic monitoring (eg, therapy adherence, therapy response, digital therapeutic intervention); device(s) supply for data access or data transmissions to support monitoring of musculoskeletal system, 2-15 days in a 30-day period
    • 98986: Remote therapeutic monitoring (eg, therapy adherence, therapy response, digital therapeutic intervention); device(s) supply for data access or data transmissions to support monitoring of cognitive behavioral therapy, 2-15 days in a 30-day period
    • 98979: Remote therapeutic monitoring treatment management services, physician or other qualified health care professional time in a calendar month requiring at least 1 real-time interactive communication with the patient or caregiver during the calendar month; first 10 minutes

    Also finalized were the updated descriptors for three additional RTM codes: 

    • 98976: Remote therapeutic monitoring (eg, therapy adherence, therapy response, digital therapeutic intervention); device(s) supply for data access or data transmissions to support monitoring of respiratory system, 16-30 days in a 30-day period
    • 98977: Remote therapeutic monitoring (eg, therapy adherence, therapy response, digital therapeutic intervention); device(s) supply for data access or data transmissions to support monitoring of musculoskeletal system, 16-30 days in a 30-day period
    • 98978: Remote therapeutic monitoring (eg, therapy adherence, therapy response, digital therapeutic intervention); device(s) supply for data access or data transmissions to support monitoring of cognitive behavioral therapy, 16-30 days in a 30-day period


  • New Webinars Posted on YouTube

    15 Apr 2025 9:30 AM | Zachary Edgar (Administrator)

    The New 2025 Medicare Referral Rule - https://youtu.be/bQxmTp3QSF8

    Arizona Medicaid Coverage of Physical Therapy Services - https://youtu.be/AfHf-aoMrhA

    California Medicaid (Medi-Cal) Coverage of Physical Therapy Services - https://youtu.be/p5StibezN_s

    California Medicaid (Medi-Cal) Coverage of Occupational Therapy Services - https://youtu.be/GmVQgceBj-M

    Illinois Medicaid Coverage of Physical, Occupational, and Speech Therapy - https://youtu.be/shLlTWcc_5s

    Florida Medicaid Coverage of Physical Therapy Services - https://youtu.be/7nK3q5S35iE

    Medicare Speech Therapy Basic Coverage Guidelines - https://youtu.be/PmXFyGyG0sQ

    California Medicaid (Medi-Cal) Coverage of Speech Therapy Services - https://youtu.be/1kiIKtSfbLs

    Florida Medicaid Coverage of Occupational Therapy - https://youtu.be/D0p3prFAygI

    Florida Medicaid Coverage of Speech Therapy Services - https://youtu.be/RBPY7lXSfOo

    New York Medicaid Coverage of Physical, Occupational and Speech Therapy - https://youtu.be/wTJKKGLXUQ0


  • 50 State Survey of Medicaid Coverage of Physical Therapy

    18 Mar 2025 8:44 AM | Zachary Edgar (Administrator)

    Medicaid coverage of physical therapy, all 50 states.

  • 50 State Survey of Medicaid Coverage of Occupational Therapy

    18 Mar 2025 8:42 AM | Zachary Edgar (Administrator)

    Medicaid coverage of occupational therapy, all 50 states. 

  • 50 State Survey of Medicaid Coverage of Speech Therapy

    18 Mar 2025 8:41 AM | Zachary Edgar (Administrator)

    Medicaid coverage of speech therapy, all 50 states.

  • Updated California Medicaid Therapy Services

    19 Jan 2025 10:33 AM | Zachary Edgar (Administrator)

    Updated California Medicaid Therapy Services.

  • Significant updates to our private insurance section

    22 Oct 2024 7:55 AM | Zachary Edgar (Administrator)

    Private Insurance

    Here members can access the physical, occupational, and speech therapy policies for commercial, Medicaid, and Medicare Advantage plans.  Members can always email us and request assistance with any issue related to therapy and private insurance. For no additional cost, members can ask questions about coverage and reimbursement policies, request a claims review, or assistance with appeals and grievances.  Members can also request that we add new insurance companies.


  • The Ohio Occupational Therapy Compliance Guides have been updated

    7 Oct 2024 4:23 PM | Zachary Edgar (Administrator)

    Ohio Occupational Therapy Compliance Guides

    We combined the Ohio statutes, board rules, and position statements to create a guide on key compliance issues for OTs and OTAs.  Members have full access to the material and can email us with questions regarding any billing or compliance issue for no additional charge, please consider joining today if you need additional assistance.   

    Updated 10/7/2024

    Definitions

    Occupational Therapy Practice

    • Scope of Practice
    • Youth Sports Concussion Management
    • Referrals - Direct Access
    • Telehealth
    • Documentation
    • Identification and Notifications 

    Supervision and Delegation

    • OT Responsibilities
    • Assistants
    • Aides
    • Students and New Graduates

    Conduct

    • Grounds for Disciplinary Action
    • Unprofessional Conduct 

    Board Statements and Forms

    Continuing Education

    • Required Hours
    • Required Courses
    • Accepted Courses and Activities
    • Course Approval
    • Record Requirements
    • Waivers and Audits 

    Licensure

    • Initial License
    • Temporary License
    • Reciprocity
    • Out-of-State Therapists 
    • Inactive or Retired Status


  • The Ohio Physical Therapy Compliance Guides have been updated

    7 Oct 2024 4:18 PM | Zachary Edgar (Administrator)

    Ohio Physical Therapy Compliance Guides

    This section is currently under construction.  Even if the guides have not been posted, members can contact us at any time with questions or requests regarding any Ohio physical therapy compliance or billing questions.  Please consider joining today if you need assistance. 

    Updated 10/7/2024

    Definitions

    Physical Therapy Practice

    • Scope of Practice
    • Referrals - Direct Access
    • Telehealth
    • Documentation
    • Notifications
    • Youth Sports

    Supervision and Delegation

    • PT Responsibilities
    • Assistants
    • Aides
    • Students and New Graduates

    Conduct

    • Grounds for Disciplinary Action
    • Unprofessional Conduct 
    • Waiver of Copayments

    Board Statements and Forms

    Continuing Education

    • Required Hours
    • Required Courses
    • Accepted Courses and Activities
    • Course Approval
    • Record Requirements
    • Waivers and Audits 

    Licensure

    • Initial License
    • Temporary License
    • Reciprocity
    • Out-of-State Therapists 
    • Inactive or Retired Status


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About Me

Zachary Edgar JD, LLM is Therapy Comply's managing partner.  Zachary is a healthcare attorney who specializes in federal and state healthcare regulatory issues particularly for physical, occupational, and speech therapy practices.  

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