By Brandon Seigel, Chief Problem Solver · September 15, 2026 · 7 min read
It's a threshold, not a cap
The old Medicare therapy cap was repealed. What's left is a threshold. Once a patient's therapy charges pass it in a calendar year, you can keep treating — but each claim needs the KX modifier to confirm the care is medically necessary and documented.
For 2026 the threshold is $2,480 for physical therapy and speech-language pathology combined, and a separate $2,480 for occupational therapy.
The targeted medical review threshold
A second line sits at $3,000 per year. Claims above it can be selected for targeted medical review. Not every claim is reviewed, but practices with high KX usage or unusual patterns are more likely to be.
The KX modifier is an attestation that the care is medically necessary and documented. Adding it without documentation to back it up creates risk.
KX, ABN, or both?
If care above the threshold is medically necessary, append KX. If care is not medically necessary and the patient wants it anyway, an Advance Beneficiary Notice (ABN) is used so the patient knows they may be responsible. You don't issue an ABN just because the patient crossed the threshold.
How we manage it daily
Our team watches threshold totals inside your EMR as claims go out every business day. That way KX is added when it's needed — and your clinicians get a heads-up when documentation needs to be stronger.
Quick answers
What is the 2026 Medicare therapy threshold?
$2,480 for physical therapy and speech-language pathology combined, and $2,480 separately for occupational therapy.
What happens above $3,000 in Medicare therapy charges?
Claims above the $3,000 targeted medical review threshold may be selected for review of medical necessity and documentation.
Sources and further reading
See exactly what's included in our medical billing services for therapy practices, how our percentage-of-collections pricing works, or browse common questions from practice owners.
Want this handled inside your EMR, every business day?
Our US-Based W2 employees work your claims daily. Tell us about your practice.
Start a conversation