Medicare’s therapy cap may be gone, but thresholds remain, and they still shape billing for physical therapy (PT), occupational therapy (OT), and speech-language pathology (SLP) services. For pt telehealth 2025, these rules apply just as they do for in-person care. The therapy threshold 2025 levels are set at $2,410 for PT and SLP combined, and $2,410 for OT separately. Once therapy services surpass these amounts, claims require the kx modifier to attest that treatment remains medically necessary. At $3,000, claims are subject to targeted medical review (TMR), meaning providers must be prepared with detailed documentation.
CMS outlines these rules clearly on its therapy services page, which remains the most authoritative reference for compliance. But providers must also understand how the thresholds intersect with telehealth, when to append modifiers, and what auditors expect when reviewing claims above these amounts.
This guide covers the 2025 dollar amounts, when to add KX, how targeted medical review works, and what to consider about Advance Beneficiary Notices (ABNs).
2025 dollar amounts
Every calendar year, CMS updates therapy thresholds based on the Medicare Economic Index. For 2025, CMS confirmed that the threshold is $2,410 for PT and SLP services combined, and $2,410 separately for OT. These thresholds apply whether services are delivered in person or via telehealth.
The policy shift from a hard therapy cap to a threshold-based system occurred in 2018, following years of congressional debate. Now, services beyond the threshold are still covered, provided the therapist attests to medical necessity by appending the kx modifier.
PT+SLP combined $2,410; OT $2,410
For therapy threshold 2025, claims should be carefully tracked by discipline. PT and SLP dollars accumulate toward the same combined $2,410 threshold, while OT services accumulate toward their own separate $2,410 threshold. CMS emphasizes that tracking is the provider’s responsibility, regardless of whether the patient receives therapy from multiple clinics.
Many practices use their EHR to flag patients nearing the threshold. For example, a PT practice delivering telehealth services may add an alert once a patient’s combined PT+SLP charges reach $2,000, ensuring that the next claim includes the kx modifier if needed.
When to add KX
The kx modifier is Medicare’s way of ensuring that claims above the threshold are only paid when services are medically necessary. Adding it tells CMS, “We know we’re above the threshold, but treatment remains essential for this patient.”
KX attests medical necessity
According to CMS guidance on therapy services, the kx modifier attests that the therapist’s documentation supports ongoing skilled care. Without it, claims above the threshold will be denied. Documentation must show not only progress toward functional goals but also why services remain reasonable and necessary.
PROMBS resources like the CMS-1500 Claim Form Guide explain how to correctly append modifiers at the line level. Internal training should emphasize that kx modifier must appear on every line that exceeds the threshold, not just the first claim over the limit.
Clinics that fail to consistently apply KX may see preventable denials pile up. A good operational strategy is embedding KX prompts into claim scrubbers once a patient’s therapy charges pass $2,410.
Targeted Medical Review at $3,000
Crossing the therapy threshold doesn’t automatically trigger an audit, but reaching $3,000 brings claims into the zone of potential targeted medical review (TMR). While not every claim above this amount is audited, CMS and contractors use data analytics to decide which ones warrant scrutiny.
What triggers targeted MR
The therapy services guidance from CMS explains that TMR can be triggered by factors such as unusually high therapy utilization, patterns inconsistent with medical necessity, or provider outliers compared to peers. The targeted medical review process means reviewers will request detailed notes, plan of care updates, progress reports, and evidence of ongoing medical necessity.
Did You Know? The Office of Inspector General has reported that therapy services have among the highest rates of improper payment in Medicare, often tied to insufficient documentation rather than fraud.
Sample claim lines above threshold
| Claim Line | CPT Code | Charge | Running Total | Modifier(s) |
|---|---|---|---|---|
| 1 | 97110 Therapeutic Exercise | $110 | $2,420 | KX |
| 2 | 97112 Neuro Re-ed | $115 | $2,535 | KX |
| 3 | 97530 Therapeutic Activity | $120 | $2,655 | KX |
In this example, every line above $2,410 includes kx modifier. Once the total passes $3,000, these claims may be selected for TMR. Documentation must fully support why therapy continues to be necessary.
ABN considerations
The Advance Beneficiary Notice (ABN) plays a role when providers believe Medicare may not cover therapy services. For example, if progress has plateaued or services appear maintenance-only, an ABN protects both provider and patient by shifting liability for payment.
According to the CMS ABN instructions, therapists should issue an ABN before delivering services they expect Medicare may deny. This includes situations where therapy continues well above thresholds without clear evidence of progress.
In the telehealth context, ABN rules still apply. Providers should deliver the notice electronically (if CMS requirements for electronic delivery are met) and document the patient’s acknowledgement.
Case Study: Telehealth PT Exceeding Thresholds
Case studies bring these policies to life. Consider a 72-year-old Medicare beneficiary recovering from a hip replacement. By July 2025, she has received 25 sessions of PT via telehealth, totaling $2,460. At this point, every additional claim line requires kx modifier.
The provider appends KX to all units above the therapy threshold 2025, carefully documenting progress toward walking without assistance. By September, the patient’s charges reach $3,200, crossing into targeted medical review territory.
When selected for review, the practice supplies:
- Initial plan of care, signed by the physician.
- Progress notes at 10th and 20th visits.
- Evidence of functional improvement, including gait scores.
- Patient consent for telehealth delivery.
Practical strategies for compliance
Compliance with thresholds, modifiers, and reviews is less about memorizing rules and more about embedding them into everyday operations. Practices that treat compliance as a one-off task often struggle with denials. Instead, successful therapy groups integrate compliance into scheduling, billing, and documentation workflows.
EHR alerts and automation
Many modern EHRs can be configured to automatically alert when a patient is approaching the therapy threshold 2025. For example, once combined PT+SLP charges reach $2,200, the EHR can generate a pop-up reminding the therapist to prepare for kx modifier use. Building this automation reduces human error and keeps compliance front of mind during busy clinics.
Modifier management
Beyond KX, therapists must also juggle telehealth-specific modifiers like modifier 95. Denials often occur because one modifier is applied but the other is missed. PROMBS’s Mastering Modifiers 59, 25, and 91 shows how cross-training staff on modifier rules prevents errors when multiple modifiers must appear on the same line.
Internal peer review
Denial management
When denials occur, appeal letters should reference CMS’s official therapy services page and cite progress notes. Practices that document unit math, functional status, and medical necessity clearly tend to succeed on appeal. Internal PROMBS guidance like Cut Prior Authorization Denials by 30% offers tactical strategies to reduce preventable denials before they occur.
Technology’s Role in Threshold Management
For clinics navigating evolving telehealth and threshold rules, technology isn’t just helpful, it’s essential. CMS strongly encourages the use of claim-scrubbing tools that flag missing modifiers and thresholds before submission, reducing compliance risk pre-emptively rather than reacting to denials. On the CMS Therapy Services page, the agency underscores the need for accurate modifier (KX) application and documentation to support medical necessity above thresholds. Many EHRs now include dashboards tracking patient charges in real time, making it easier to flag when therapy charges approach the annual therapy threshold 2025.
Some providers are going even further by leveraging artificial intelligence (AI) to predict when a patient is likely to exceed the $3,000 TMR threshold. These AI tools analyze usage trends and functional outcomes, alerting clinicians early to schedule progress evaluations. Research summarized by healthcare technology analysts, such as those at the Kaiser Family Foundation (KFF), points to these predictive analytics as transformative for reducing improper payments and audit risk.
A notable case involves a multi-site rehab network that integrated a real-time alert system into their EHR. As soon as patients approached $2,410 in PT/SLP charges or $2,410 in OT charges, the system flagged the account. This real-time visibility helped ensure that the kx modifier was applied promptly and that detailed progress documentation was prepared for possible targeted medical review at $3,000. After deployment, the network reported a 35 percent reduction in threshold-related denials within six months.
Embedding such technology into your revenue cycle, especially when paired with educational tools like the PROMBS CMS-1500 Claim Form Guide and the POS 10 Telehealth Guide, creates both a safety net and operational clarity. It ensures compliance, frees clinicians from manual monitoring, and strengthens audit readiness.
Therapy Thresholds & Compliance
To anchor the amounts in a single snapshot, use the following tables as a quick reference, the figures come straight from the CMS Therapy Services hub, which states that for CY 2025 the KX modifier threshold is $2,410 for PT and SLP combined and $2,410 for OT, and from CMS’s CY 2025 annual update transmittal, which confirms the same dollar amounts and explains how thresholds are indexed by the MEI. You can verify both the thresholds and the ongoing review framework by reading the policy text on the Therapy Services page and the CY 2025 transmittal before you submit claims above the line.
| 2025 Thresholds | PT + SLP | OT |
|---|---|---|
| KX modifier threshold (CY 2025) | $2,410 | $2,410 |
| Action once above threshold | Append KX on each claim line that exceeds the threshold and ensure documentation supports medical necessity | Append KX on each claim line that exceeds the threshold and ensure documentation supports medical necessity |
Because reviewers frequently ask where these dollar amounts originate, it helps to note in your policy that the KX modifier threshold is updated annually and that claims above the threshold without KX are denied, which CMS reiterates in program-integrity guidance that references the same statutory framework behind the threshold policy.
Preparing for 2026 and Beyond
Although the current rules extend telehealth therapy eligibility through September 30, 2025, the broader framework around thresholds and reviews will continue in 2026. The therapy threshold 2025 will reset with inflation, likely increasing slightly in dollar amount. The kx modifier will remain essential, and targeted medical review will continue to focus on outlier claims.
Industry analysts at KFF and policy experts writing in Health Affairs note that Congress may revisit telehealth coverage in 2025–26, especially if data shows continued access benefits. Clinics that build strong compliance workflows now will be well positioned regardless of policy changes.
The key for providers is to keep staff trained, update EHR prompts annually for new thresholds, and continue documenting functional progress meticulously. This approach ensures smooth adaptation whether telehealth policies are extended, scaled back, or made permanent.
Conclusion
For pt telehealth 2025, the therapy thresholds remain pivotal. At $2,410 for PT/SLP combined and $2,410 for OT, claims beyond this level require the kx modifier to attest medical necessity. Once total charges exceed $3,000, providers should be prepared for targeted medical review, ensuring that documentation can withstand scrutiny. In cases where services may no longer meet Medicare’s standards, an ABN should be issued.
By following CMS’s official therapy services guidance and leveraging internal resources like the CMS-1500 Claim Form Guide, Mastering Modifiers 59, 25, and 91, and Specialties, providers can balance compliance with patient care.
The rules may feel administrative, but they are essential to sustaining access, avoiding denials, and ensuring that therapy services, whether in-person or via telehealth, continue to support patient outcomes in 2025.
