Georgia Medicare Outpatient Rehabilitation Services Benefit

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By Brevy Care Team · Last verified May 13, 2026

Physical therapy, occupational therapy, and speech-language pathology are essential Medicare Part B benefits for Georgia beneficiaries recovering from strokes, joint replacements, falls, dysphagia, and managing chronic neurological conditions. Section 1861(p) of the Social Security Act establishes outpatient physical therapy services as a Medicare benefit, Section 1861(g) establishes outpatient occupational therapy, and Section 1861(ll) establishes speech-language pathology services. For two decades, beneficiaries faced annual financial "therapy caps" under Section 1833(g) that limited combined physical and speech therapy and separately capped occupational therapy. The Bipartisan Budget Act of 2018 Section 50202 permanently repealed the therapy cap retroactive to January 1, 2018, replacing it with a KX modifier threshold and a targeted medical review threshold. The Jimmo v. Sebelius 2013 federal class action settlement rejected the prior "improvement standard" and confirmed that Medicare covers maintenance therapy when skilled care is required, even without expected functional gains. This guide explains the federal statutory and regulatory framework, the KX modifier process, plan of care requirements, the Jimmo standard, the comprehensive outpatient rehabilitation facility benefit, the personnel and supervision rules, and how Georgia beneficiaries access PT, OT, and SLP through hospital outpatient departments, freestanding clinics, and other settings. :::

::: callout Key takeaways for Georgia outpatient rehabilitation:

1. Section 1861(p), 1861(g), and 1861(ll) of the Social Security Act establish outpatient physical therapy, occupational therapy, and speech-language pathology as Medicare Part B benefits. Section 1861(s)(2)(D) brings physical therapy services into the Part B coverage clause; comparable provisions cover OT and SLP.

2. Bipartisan Budget Act of 2018 Section 50202 permanently repealed the Section 1833(g) therapy cap retroactive to January 1, 2018. The longstanding annual financial limit on PT/SLP combined and the separate limit on OT no longer apply.

3. KX modifier threshold replaces the old cap as a documentation trigger. In 2026 approximately $2,410 for combined PT and SLP and approximately $2,410 for OT. The provider attaches the KX modifier and attests medical necessity to continue covered services above the threshold.

4. Targeted medical review threshold remains at $3,000 for PT/SLP combined and $3,000 for OT through 2027. Only providers identified by CMS data analysis face actual review at that level; not all claims above $3,000 trigger an audit.

5. 42 CFR 410.61 plan of care requirements mandate that a plan of care be established before treatment, certified by a physician, NP, PA, or CNS within 30 days, and recertified at least every 90 days. Plans of care must include diagnoses, long-term goals, type of therapy, amount, frequency, and duration.

6. Jimmo v. Sebelius 2013 settlement rejected the prior "improvement standard." Medicare cannot deny therapy on the basis that the beneficiary is not improving; maintenance therapy is covered when skilled services are required. CMS issued clarifying transmittals in 2014 and a court-ordered educational campaign in 2017.

7. Personnel and supervision rules require PTs, OTs, and SLPs to meet Medicare qualifications: appropriate degree, national examination, state licensure, and (for SLPs) the ASHA Certificate of Clinical Competence. Services furnished "in whole or in part" by a PTA or COTA are paid at 85% of the otherwise applicable rate effective January 1, 2022, with the CQ or CO modifier required.

8. Palmetto GBA Jurisdiction J serves as the Medicare Administrative Contractor for Georgia, Alabama, and Tennessee Part B claims. Palmetto issues local coverage determinations governing therapy services in Georgia. :::

Federal Statutory and Regulatory Authority for Medicare Outpatient Rehabilitation

The Medicare outpatient rehabilitation benefit rests on a multi-statute framework that defines who can provide therapy, where, under what supervision, with what documentation, and at what payment rate. Georgia beneficiaries and the families helping them navigate care should understand the statutory backbone because most coverage disputes resolve to one of these specific provisions.

Section 1861(p) of the Social Security Act: Outpatient Physical Therapy

Section 1861(p) of the Social Security Act, codified at 42 U.S.C. 1395x(p), defines "outpatient physical therapy services" as physical therapy services furnished by a provider of services, clinic, rehabilitation agency, or public health agency, or by others under arrangements with and under the supervision of such a provider, clinic, rehabilitation agency, or public health agency, to an individual who is under the care of a physician.

The statute requires services to be furnished pursuant to a written plan of care established by a physician or by a qualified physical therapist after consultation with the physician. Section 1861(p) has been part of Medicare since the program's early years, with formal outpatient PT benefits taking modern shape through legislation in the 1970s.

Section 1861(g) of the Social Security Act: Outpatient Occupational Therapy

Section 1861(g) defines "outpatient occupational therapy services" using parallel language to Section 1861(p). Occupational therapy was added to the Medicare benefit package through the Omnibus Budget Reconciliation Act of 1980 (Public Law 96-499). The statute requires:

• Plan of care established by a physician or qualified occupational therapist
• Services furnished by qualified personnel
• Periodic review and physician consultation
• Medical necessity under Section 1862(a)(1)(A)

Section 1861(ll) of the Social Security Act: Speech-Language Pathology

Section 1861(ll) was added to the Social Security Act by the Balanced Budget Act of 1997. The statute defines "speech-language pathology services" as such speech, language, and related function assessment and rehabilitation services furnished by a qualified speech-language pathologist as the speech-language pathologist is legally authorized to perform under State law (or the State regulatory mechanism provided by State law) as would otherwise be covered if furnished by a physician.

Speech-language pathology services include:

• Speech sound production assessment
• Voice and resonance assessment and treatment
• Language assessment and treatment (expressive and receptive)
• Cognitive-communication assessment and treatment
• Dysphagia (swallowing) assessment and treatment, including instrumental swallowing studies
• Augmentative and alternative communication evaluations
• Auditory rehabilitation services

The qualified speech-language pathologist must hold a master's degree from an accredited program, complete a clinical fellowship, pass the Praxis SLP examination, and hold the Certificate of Clinical Competence in Speech-Language Pathology (CCC-SLP) from the American Speech-Language-Hearing Association (ASHA) or meet equivalent state licensure requirements.

Section 1861(s)(2)(D) of the Social Security Act: Part B Coverage Clause

Section 1861(s)(2)(D) includes outpatient physical therapy services within "medical and other health services" covered under Medicare Part B. This is the operational coverage clause that brings PT, OT, and SLP into Part B and triggers Part B cost-sharing rules (Part B deductible and 20% coinsurance).

Section 1861(cc) of the Social Security Act: Comprehensive Outpatient Rehabilitation Facility

Section 1861(cc), added in 1980, defines the comprehensive outpatient rehabilitation facility (CORF) benefit. A CORF is a physician-directed, multidisciplinary outpatient rehabilitation provider that delivers PT, OT, SLP, social services, psychological services, prosthetic and orthotic services, nursing care, drugs and biologicals, supplies, and respiratory therapy under a coordinated plan of care.

Despite the comprehensive benefit, CORFs are very rare in practice. Nationally, fewer than 200 CORFs operate, with most concentrated in Florida. Georgia has very few CORFs, and most outpatient rehabilitation is delivered through hospital outpatient departments and freestanding outpatient clinics rather than CORFs.

Section 1833(g) of the Social Security Act: The Therapy Cap (Repealed 2018)

Section 1833(g), enacted by the Balanced Budget Act of 1997 (Public Law 105-33) Section 4541, established the original therapy cap. Originally the cap was structured as:

• An annual financial cap on outpatient PT and SLP combined services
• A separate annual financial cap on outpatient OT services
• Cap amounts indexed annually based on the Medicare Economic Index

The therapy cap was the most contentious Medicare outpatient policy of the 1997 through 2018 era. Congress repeatedly enacted moratoria delaying enforcement, and an "exceptions process" via the KX modifier allowed beneficiaries to receive services above the cap when medically necessary.

The Bipartisan Budget Act of 2018 Section 50202, signed February 9, 2018, permanently repealed the Section 1833(g) therapy cap retroactive to January 1, 2018. The repeal was not a complete elimination of limits. Section 50202 created two replacement mechanisms:

KX Modifier Threshold. The KX modifier threshold replaces the old cap dollar amount as a documentation trigger. The beneficiary may continue receiving covered therapy above the threshold if the provider attaches the KX modifier attesting that services are medically necessary. For 2026 the threshold is approximately $2,410 for PT and SLP combined and approximately $2,410 for OT. The threshold updates annually based on the Medicare Economic Index.

Targeted Medical Review Threshold. The targeted medical review (TMR) threshold replaces the old manual medical review threshold. It is set at $3,000 for PT/SLP combined and $3,000 for OT through CY 2027. Importantly, not all claims above the TMR threshold are reviewed: only providers identified through CMS data analysis face actual review. The threshold is statutory through 2027.

Section 1833(a)(8) of the Social Security Act: Payment

Section 1833(a)(8) governs payment for outpatient PT, OT, and SLP. Payment is at the lesser of the actual charge or the Medicare Physician Fee Schedule (MPFS) amount for the service. After Medicare's payment, the beneficiary is responsible for:

• The Part B annual deductible (in 2026: $257)
• 20% coinsurance of the Medicare-approved amount

A Medigap policy can cover the 20% coinsurance. Medicare Advantage plans cover the same services at least as comprehensively as Original Medicare but may apply different cost-sharing (typically per-visit copays in lieu of coinsurance).

Section 1862(a)(1)(A) of the Social Security Act: Reasonable and Necessary

Section 1862(a)(1)(A) requires that all Medicare services be reasonable and necessary for the diagnosis or treatment of illness or injury. This is the foundational medical necessity requirement applied to every therapy claim. For outpatient therapy, medical necessity requires:

• Skilled services that require the judgment of a qualified PT, OT, or SLP
• Services consistent with the beneficiary's diagnosis and condition
• Effective treatment likely to result in functional improvement or, under Jimmo, maintenance of function
• Frequency, duration, and intensity appropriate to the condition

Section 1862(a)(20) of the Social Security Act: Qualifications

Section 1862(a)(20) requires that outpatient therapy be furnished by qualified personnel and under appropriate supervision and pursuant to a plan of care meeting the regulatory standards.

42 CFR 410.59: Outpatient Occupational Therapy Services

42 CFR 410.59 sets forth coverage requirements for outpatient OT:

• Services furnished by qualified OT or qualified OTA under supervision
• Plan of care established and reviewed under 42 CFR 410.61
• Services reasonable and necessary
• Coverage includes therapeutic exercise, activities of daily living training, sensory integration, fine motor training, and adaptive equipment training

42 CFR 410.60: Outpatient Physical Therapy Services

42 CFR 410.60 sets forth coverage requirements for outpatient PT:

• Services furnished by qualified PT or qualified PTA under supervision
• Plan of care established under 42 CFR 410.61
• Services reasonable and necessary
• Coverage includes therapeutic exercise, manual therapy, modalities (heat, cold, ultrasound, electrical stimulation), gait training, balance training, and patient education

42 CFR 410.61: Plan of Care Requirements

42 CFR 410.61 establishes the plan of care framework for outpatient therapy services.

Plan of Care Establishment. The plan must be established before treatment begins. It may be established by a physician, nurse practitioner, physician assistant, clinical nurse specialist, or qualified therapist (PT, OT, SLP). If established by the therapist, the plan must be reviewed and signed by a physician, NP, PA, or CNS within 30 days.

Plan of Care Content. The plan must include:

• Diagnoses (medical conditions requiring therapy)
• Long-term treatment goals
• Type of therapy (PT, OT, SLP)
• Amount of therapy (number of times per session)
• Frequency of therapy (sessions per week)
• Duration of therapy (number of weeks)

Recertification. The plan must be recertified at least every 90 days. Recertification requires that the physician, NP, PA, or CNS review and sign the updated plan. Documentation must support continued medical necessity for the recertification period.

42 CFR 410.62: Outpatient Speech-Language Pathology Services

42 CFR 410.62 sets forth coverage requirements for outpatient SLP:

• Services furnished by qualified SLP
• Plan of care established under 42 CFR 410.61
• Services reasonable and necessary
• Coverage includes speech, language, voice, cognitive-communication, dysphagia, and augmentative and alternative communication services

42 CFR Part 485 Subpart B: CORF Conditions of Participation

42 CFR 485.701 through 485.729 establish the conditions of participation for comprehensive outpatient rehabilitation facilities. Requirements include physician direction, multidisciplinary team coordination, plan of care every 60 days, personnel qualifications meeting Medicare standards, comprehensive patient assessment, quality of care monitoring, appropriate physical environment, and protection of patient rights.

Statutory History of the Therapy Cap and Its Repeal

Understanding the history of the therapy cap helps Georgia beneficiaries appreciate why the KX modifier threshold exists today and what protections they have above and below it.

1997 Balanced Budget Act: Therapy Cap Established

The Balanced Budget Act of 1997 Section 4541 established the original Section 1833(g) therapy cap as part of broader Medicare cost-control measures. The initial structure:

• $1,500 combined cap on PT and SLP services
• Separate $1,500 cap on OT services
• Cap applied per beneficiary per year
• Did not apply to therapy delivered in hospital outpatient departments initially

The cap immediately drew controversy from beneficiary advocates, therapy professional associations, and Members of Congress representing seniors. Stories emerged of seniors recovering from strokes, joint replacements, and other conditions running out of therapy mid-recovery.

Repeated Moratoria 1999 through 2017

Congress responded to the cap controversy with a series of moratoria delaying enforcement:

• Balanced Budget Refinement Act of 1999: first two-year moratorium
• Benefits Improvement and Protection Act of 2000: moratorium extension
• Medicare Modernization Act of 2003: moratorium through 2005
• Deficit Reduction Act of 2005: exceptions process via KX modifier created
• Multiple Continuing Extensions through 2017

The 2006 Deficit Reduction Act created the KX modifier exceptions process. Under the exceptions process, beneficiaries could receive therapy above the cap if the provider documented medical necessity and attached the KX modifier.

2012 Manual Medical Review

The Middle Class Tax Relief and Job Creation Act of 2012 created a Manual Medical Review (MMR) threshold at $3,700. Claims at or above $3,700 required mandatory pre-payment medical review. The MMR threshold remained in effect from 2012 through 2017.

2018 Permanent Repeal

The Bipartisan Budget Act of 2018, signed February 9, 2018, Section 50202 permanently repealed the Section 1833(g) therapy cap retroactive to January 1, 2018. The repeal eliminated the dollar-amount cap on Medicare coverage of outpatient therapy but established the KX modifier threshold and targeted medical review threshold framework that continues today.

The repeal was the result of years of advocacy by the American Physical Therapy Association, the American Occupational Therapy Association, the American Speech-Language-Hearing Association, and beneficiary groups. The repeal was widely celebrated as a major win for seniors and rehabilitation patients.

The KX Modifier Threshold

The KX modifier threshold is the most important practical concept for Georgia beneficiaries to understand about outpatient therapy.

What the Threshold Is and What It Is Not

The KX modifier threshold is a documentation trigger: not a coverage limit. When a beneficiary's accumulated therapy charges reach the threshold, the provider must attach the KX modifier to claim lines for additional therapy services. The KX modifier is a written attestation by the provider that the services are reasonable and necessary.

The threshold is not a hard cap. Coverage continues above the threshold for as long as services remain medically necessary and documented.

2026 Thresholds

For 2026 the KX modifier threshold is approximately $2,410 for PT and SLP combined and approximately $2,410 for OT. (Beneficiaries should always verify the current-year threshold via Medicare.gov or 1-800-MEDICARE.)

Targeted Medical Review Threshold

The targeted medical review (TMR) threshold remains at $3,000 for PT/SLP combined and $3,000 for OT through CY 2027. Above the TMR threshold, providers identified by CMS data analysis (based on aberrant billing patterns, high denial rates, or other factors) may face actual prepayment or postpayment medical review. Most beneficiaries above the TMR threshold do not face individual review: only the targeted provider's claims are reviewed.

How the KX Modifier Process Works in Practice

When a Georgia beneficiary approaches the KX threshold:

1. The provider's billing system tracks accumulated charges against the threshold
2. When approaching the threshold, the provider reviews the plan of care for medical necessity documentation
3. For claim lines above the threshold, the provider attaches the KX modifier
4. The KX modifier attests that services are reasonable and necessary based on the medical record
5. Documentation must support medical necessity for the period above the threshold
6. Audit risk increases above the threshold, particularly for providers approaching the TMR threshold

The KX modifier is not a request for prior authorization: it is an attestation. Medicare pays the claim in the ordinary course; review (if any) occurs through targeted post-payment audit or pre-payment review for targeted providers.

The Jimmo v. Sebelius Settlement and Maintenance Therapy

The Jimmo v. Sebelius settlement is among the most important Medicare court decisions of the past two decades for therapy coverage.

Background: The Improvement Standard

Before Jimmo, Medicare contractors routinely applied an "improvement standard" to therapy claims. Under this standard, services were covered only if the beneficiary was expected to improve functionally. Claims for therapy aimed at maintaining current function (rather than achieving new functional gains) were routinely denied.

The improvement standard was particularly harmful to beneficiaries with progressive conditions: Parkinson's disease, multiple sclerosis, ALS, dementia, and other neurological disorders where the goal of therapy is often to maintain function as long as possible rather than to "improve" against the underlying disease.

The Lawsuit and Settlement

Glenda Jimmo, a Vermont woman with cardiac disease and other conditions, brought a federal class action lawsuit challenging the improvement standard. The case was joined by additional plaintiffs and was certified as a nationwide class action.

In 2013, the parties reached a settlement that was approved by the U.S. District Court for the District of Vermont on January 24, 2013. The settlement included:

• An agreement that Medicare cannot deny coverage solely because the beneficiary is not improving
• Confirmation that maintenance therapy is covered when skilled services are required
• Required CMS to issue clarifying transmittals
• Required CMS to conduct an educational campaign for adjudicators and providers

The Jimmo Standard Today

Under the Jimmo standard, Medicare coverage of skilled therapy depends on whether the services require the skilled judgment of a PT, OT, or SLP, not on whether the beneficiary is expected to improve. Coverage extends to:

• Maintenance therapy for chronic and progressive conditions
• Skilled therapy aimed at preventing decline
• Therapy to maintain functional status
• Therapy to slow the progression of functional loss

The skilled services standard means coverage focuses on the complexity of intervention. A therapist's professional judgment must be required: not exercises that could be performed by an unskilled person.

CMS Implementation

CMS issued implementing transmittals in 2014 to update the Medicare Benefit Policy Manual, and a court-ordered educational campaign in 2017 to clarify the standard for adjudicators and providers. The Jimmo standard applies to outpatient therapy, home health therapy, and skilled nursing facility therapy.

Practical Implication for Georgia Beneficiaries

A Georgia beneficiary with Parkinson's disease attending weekly maintenance LSVT BIG sessions at Atrium Health Navicent is entitled to coverage under Jimmo, even though she is not "improving." The therapist's professional judgment in applying the LSVT protocol qualifies as skilled care. Documentation should reflect the skilled nature of the intervention, the patient's response, and continuing medical necessity.

Personnel and Supervision Requirements

Medicare imposes detailed personnel and supervision requirements for outpatient therapy.

Physical Therapist Requirements

A qualified physical therapist must:

• Have graduated from an accredited PT program (currently CAPTE-accredited; entry-level Doctor of Physical Therapy since 2015)
• Have passed the National Physical Therapy Examination (NPTE)
• Hold a current state license in good standing
• Meet Medicare credentialing requirements

In Georgia, PTs are licensed by the Georgia State Board of Physical Therapy.

Physical Therapist Assistant Requirements

A qualified physical therapist assistant must:

• Have graduated from an accredited PTA program (CAPTE)
• Have passed the National Physical Therapy Examination for PTAs
• Hold a current state license in good standing
• Work under PT supervision per state law and Medicare rules

PTA and COTA Payment Reduction

Effective January 1, 2022, Section 53107 of the Bipartisan Budget Act of 2018 requires that services furnished "in whole or in part" by a PTA be paid at 85% of the otherwise applicable PT rate. The CQ modifier must be attached to PT claim lines when a PTA furnished the services.

Parallel rules apply to OT services furnished by an OTA (also called certified occupational therapy assistant or COTA): 85% payment rate, CO modifier required.

The PTA/COTA payment reduction does not apply to speech-language pathology because SLP services have no Medicare-recognized assistant role for billing purposes.

Occupational Therapist Requirements

A qualified occupational therapist must:

• Have graduated from an ACOTE-accredited OT program
• Have passed the NBCOT national examination
• Hold a current state license in good standing
• Meet Medicare credentialing requirements

In Georgia, OTs are licensed by the Georgia State Board of Occupational Therapy.

Occupational Therapy Assistant Requirements

A qualified OTA must:

• Have graduated from an ACOTE-accredited OTA program
• Have passed the NBCOT examination for OTAs
• Hold a current state license in good standing

Speech-Language Pathologist Requirements

A qualified SLP must:

• Hold a master's degree from an accredited program
• Have completed a clinical fellowship (typically 9 to 12 months)
• Have passed the Praxis SLP examination
• Hold the CCC-SLP from ASHA or meet equivalent state licensure standards
• Hold a current Georgia license from the Georgia Board of Examiners for Speech-Language Pathology and Audiology

There is no Medicare-recognized SLP assistant equivalent to PTA/COTA. All Medicare-billable SLP services must be furnished by a qualified SLP.

Service Locations and Payment Methodology

Outpatient therapy is furnished in multiple settings, each with its own payment rules.

Hospital Outpatient Department

When PT, OT, or SLP is furnished in a hospital outpatient department, payment may be under the Outpatient Prospective Payment System (OPPS) or under the Medicare Physician Fee Schedule depending on the specific service and the hospital's billing structure. KX modifier threshold and TMR threshold apply.

Private Outpatient Clinic and Rehabilitation Agency

Most outpatient therapy is delivered in private outpatient clinics and rehabilitation agencies. Payment is under the Medicare Physician Fee Schedule. The KX modifier threshold applies. The Part B annual deductible ($257 in 2026) and 20% coinsurance apply.

Skilled Nursing Facility (Part B Outpatient)

When a Medicare beneficiary resides in a skilled nursing facility but is not under a Part A SNF stay (for example, custodial residents who are private-pay or Medicaid-funded), therapy is billed under Part B. KX modifier threshold and TMR threshold apply.

When the beneficiary is under a Part A SNF stay, therapy is included in the consolidated per diem payment under the Patient Driven Payment Model (PDPM) and is not separately billable under Part B.

Home Health Agency

Therapy delivered under a Part A home health episode is paid under the Home Health Prospective Payment System (HH PPS) and is not subject to the KX modifier threshold.

For beneficiaries who do not qualify for the home health benefit but receive outpatient therapy in the home (for example, a homebound beneficiary outside a home health episode), the therapy may be billable as Part B outpatient therapy in limited circumstances.

Comprehensive Outpatient Rehabilitation Facility

CORF therapy services are paid under the Medicare Physician Fee Schedule for the PT, OT, and SLP components; other CORF services (nursing, social, psychological, respiratory) are paid under separate rules. KX modifier threshold and TMR threshold apply.

Common HCPCS and CPT Codes for Outpatient Therapy

Outpatient therapy is billed using CPT codes maintained by the American Medical Association (with some HCPCS Level II codes for specialized services).

Physical Therapy Codes

Evaluation codes:

• 97161: PT evaluation, low complexity
• 97162: PT evaluation, moderate complexity
• 97163: PT evaluation, high complexity
• 97164: PT re-evaluation

Treatment codes (time-based, 15-minute units):

• 97110: Therapeutic exercise
• 97112: Neuromuscular re-education
• 97116: Gait training
• 97140: Manual therapy
• 97530: Therapeutic activities
• 97535: Self-care/home management training
• 97542: Wheelchair management
• 97750: Physical performance test

Occupational Therapy Codes

Evaluation codes:

• 97165: OT evaluation, low complexity
• 97166: OT evaluation, moderate complexity
• 97167: OT evaluation, high complexity
• 97168: OT re-evaluation

Treatment codes (shared with PT and OT-specific):

• 97110, 97112, 97140, 97530, 97535, 97542 (shared time-based codes)
• 97533: Sensory integrative techniques
• 97537: Community/work reintegration

Speech-Language Pathology Codes

Evaluation codes:

• 92521: Speech sound production evaluation
• 92522: Speech sound production with language evaluation
• 92523: Speech sound production with language and voice evaluation
• 92524: Voice and resonance evaluation

Treatment codes:

• 92507: Speech, language, voice, communication, auditory processing treatment
• 92526: Treatment of swallowing dysfunction
• 92610: Evaluation of oral and pharyngeal swallowing function
• 92611: Motion fluoroscopic evaluation of swallowing
• 96125: Standardized cognitive performance testing

Documentation Requirements

Medicare requires detailed documentation for outpatient therapy. The medical record must support medical necessity and the plan of care.

Initial Evaluation Documentation

The initial evaluation must document:

• Patient history including current condition, prior level of function, and goals
• Subjective symptoms
• Objective findings (range of motion, strength, balance, speech production, swallowing function, cognitive status, as applicable)
• Assessment and clinical impression
• Plan of care including diagnoses, long-term goals, type/amount/frequency/duration

Daily Treatment Notes

Each treatment session requires documentation of:

• Date and time of service
• Total treatment time
• Specific interventions and units billed
• Patient response to treatment
• Clinical decision making

Progress Notes

Progress notes must be written periodically (typically every 10 visits or 30 days, whichever is sooner) and must document:

• Assessment of progress toward goals
• Updates to long-term goals
• Justification for continued therapy
• Coordination with referring provider

Recertification Documentation

At each 90-day recertification, documentation must support continued medical necessity. The physician, NP, PA, or CNS must review and sign the updated plan of care.

Palmetto GBA Jurisdiction J: Georgia's Medicare Administrative Contractor

Palmetto GBA serves as the Medicare Administrative Contractor for Jurisdiction J Part B, covering Georgia, Alabama, and Tennessee. Palmetto's responsibilities include:

• Processing Part B claims for outpatient therapy services
• Issuing Local Coverage Determinations (LCDs) governing therapy
• Setting frequency and duration expectations
• Conducting medical reviews including targeted review of providers above the TMR threshold
• Provider education

Relevant LCDs include LCD L33631 (Outpatient Physical and Occupational Therapy Services) and LCD L34049 (Speech-Language Pathology Services). Palmetto can be reached at 1-877-567-9230 or via palmettogba.com.

When a Georgia beneficiary's therapy claim is denied, the first level of appeal (redetermination) is filed with Palmetto GBA. Subsequent levels (reconsideration, ALJ hearing, Medicare Appeals Council, federal court) follow the standard five-level Medicare appeals process.

Georgia Outpatient Rehabilitation Landscape

Georgia beneficiaries have substantial access to outpatient rehabilitation services through hospital outpatient departments, freestanding clinics, and specialized rehabilitation providers.

Hospital Outpatient Rehabilitation Departments

Major Georgia hospital systems with outpatient rehab departments:

• Emory Healthcare (Atlanta metro): Emory Rehabilitation Hospital plus multiple outpatient clinics affiliated with Emory University Hospital, Emory University Hospital Midtown, Emory Saint Joseph's, Emory Johns Creek, Emory Decatur
• Piedmont Healthcare (statewide): Piedmont Atlanta, Piedmont Athens Regional, Piedmont Columbus Regional, Piedmont Macon, Piedmont Newnan, Piedmont Henry, Piedmont Rockdale, Piedmont Eastside, Piedmont Fayette, Piedmont Mountainside, Piedmont Walton, Piedmont Cartersville
• Wellstar Health System (West Georgia, Atlanta metro): Wellstar Kennestone, Wellstar Cobb, Wellstar Douglas, Wellstar North Fulton, Wellstar Paulding, Wellstar Spalding Regional, Wellstar Sylvan Grove
• Northeast Georgia Health System (Gainesville-Braselton): NGMC Gainesville, NGMC Braselton, NGMC Barrow, NGMC Lumpkin
• Memorial Health (Savannah): Memorial Health University Medical Center outpatient rehab
• Augusta University Health: AU Medical Center rehab
• Atrium Health Navicent (Macon): Navicent rehab; LSVT BIG and LSVT LOUD certified clinicians
• Phoebe Putney Memorial Hospital (Albany): Phoebe Rehab Services
• Grady Health System (Atlanta): Grady outpatient rehab
• Tanner Health System (West Georgia)
• St. Mary's Health Care System (Athens)
• Tift Regional Medical Center (Tifton)
• Houston Healthcare (Warner Robins)

Inpatient Rehabilitation Facilities with Outpatient Components

Several Georgia inpatient rehabilitation facilities offer outpatient services to discharged patients and the community:

• Shepherd Center (Atlanta): nationally renowned spinal cord injury and brain injury specialty rehabilitation
• Emory Rehabilitation Hospital (Atlanta)
• Encompass Health Rehabilitation Hospital (multiple Georgia locations including Atlanta, Augusta, Savannah, Macon, Columbus, Newnan)

National Outpatient PT Chains in Georgia

Several national outpatient physical therapy chains operate Georgia locations:

• Athletico Physical Therapy
• ATI Physical Therapy
• Drayer Physical Therapy Institute
• Benchmark Physical Therapy (part of Upstream Rehabilitation)
• Results Physiotherapy
• Select Physical Therapy
• Ivy Rehab
• Foothills Sports Medicine and Rehab
• Pivot Physical Therapy
• US Physical Therapy
• Empower Physical Therapy

Comprehensive Outpatient Rehabilitation Facilities in Georgia

CORFs are extremely rare. Most outpatient rehab in Georgia is delivered through hospital outpatient departments or freestanding clinics rather than CORFs. Beneficiaries who see a facility advertising as a CORF should verify the designation against the Medicare provider enrollment database.

Georgia State Licensing Boards

All three rehabilitation disciplines are licensed in Georgia under the Secretary of State Professional Licensing Boards Division (phone 478-207-2440):

• Georgia State Board of Physical Therapy
• Georgia State Board of Occupational Therapy
• Georgia Board of Examiners for Speech-Language Pathology and Audiology

Beneficiaries can verify a therapist's license status through the Georgia Secretary of State's Verify a License portal.

Worked Examples for Georgia Beneficiaries

The following examples illustrate how the federal framework applies to Georgia beneficiaries in common clinical scenarios. Names and details are illustrative.

Example 1: Margaret, Age 78, Atlanta: Post-Stroke Rehabilitation

Margaret had an ischemic stroke and completed inpatient rehabilitation at Shepherd Center. She is discharged home with right hemiparesis, mild expressive aphasia, and dysphagia. Her physician at Piedmont Atlanta refers her for outpatient PT, OT, and SLP at Piedmont Atlanta's outpatient rehab department.

Margaret begins therapy 3x/week for PT (gait training, balance, right upper extremity), 2x/week for OT (ADL retraining, fine motor recovery), and 2x/week for SLP (language therapy, dysphagia treatment). After 8 weeks her combined PT/SLP charges reach $2,500: above the $2,410 KX threshold. Her therapists document continued medical necessity for skilled services. PT documents impaired gait, persistent balance deficits, and active rehabilitation goals. SLP documents continuing aphasia recovery and dysphagia improvement. The therapy team attaches the KX modifier to subsequent claims.

Margaret's combined OT charges remain at approximately $1,200: below the OT threshold. No KX modifier needed for OT yet.

Medicare continues to pay 80% after her $257 Part B deductible has been met. Her Medigap Plan G covers the 20% coinsurance, so Margaret has no out-of-pocket cost.

Example 2: Robert, Age 82, Savannah: Total Knee Replacement Recovery

Robert had a right total knee arthroplasty performed at Memorial Health University Medical Center. He starts outpatient PT at ATI Physical Therapy in Savannah three times per week beginning 2 weeks post-op.

Standard course: 8 to 10 weeks of outpatient PT focused on knee flexion, quadriceps strengthening, gait normalization, and return to functional activities. Total billed PT charges: approximately $1,800: below the $2,410 KX threshold. No special documentation needed beyond the standard plan of care, daily notes, and progress notes.

Robert has Original Medicare with a Medigap Plan N. He pays the Part B deductible at his first visit ($257); the 20% coinsurance is covered by his Medigap. Robert returns to full function at 10 weeks post-op.

Example 3: Linda, Age 75, Macon: Parkinson's Disease LSVT BIG and LOUD

Linda has Parkinson's disease with bradykinesia and hypophonic speech (soft voice). Her neurologist at Atrium Health Navicent refers her for LSVT BIG (physical therapy) and LSVT LOUD (speech-language pathology) at Atrium Navicent's rehab department. The Navicent therapists are LSVT-certified.

The standard LSVT BIG and LOUD protocol is 16 sessions over 4 consecutive weeks (4 sessions per week). After completing the intensive 4-week course, Linda transitions to maintenance therapy 1x/week for ongoing skill preservation.

Under Jimmo v. Sebelius, Linda's maintenance therapy is covered. The therapists document the skilled nature of LSVT BIG and LOUD interventions (specific cueing, complex motor and vocal exercises requiring professional judgment), Linda's response, and continuing medical necessity. Because Linda is not "improving" but Jimmo confirms maintenance therapy is covered when skilled services are required, Medicare continues to pay.

Linda has a Medicare Advantage plan with a $35 per visit copay for outpatient therapy. The plan does not impose any annual cap inconsistent with Part B.

Example 4: Charles, Age 80, Augusta: Conservative Low Back Pain Care

Charles has chronic low back pain and right-sided sciatica without surgical indications. His primary care physician at AU Medical Center refers him to outpatient PT at AU Medical Center's outpatient rehab department.

Treatment includes manual therapy (mobilization), McKenzie-method exercises, core stabilization, neural mobilization, and patient education. Charles attends 2x/week for 6 weeks (12 visits total). Total charges: approximately $1,200: well below the KX threshold.

After 6 weeks Charles has substantial pain reduction and improved functional capacity. The PT discharges him to an independent home exercise program. Medicare paid 80% after his deductible; his retiree health plan covered the 20% coinsurance.

Example 5: Patricia, Age 73, Columbus: Dysphagia Post-Radiation

Patricia completed radiation therapy for laryngeal cancer at Piedmont Columbus Regional and now has post-radiation dysphagia and odynophagia. Her oncologist refers her to the Piedmont Columbus SLP service for dysphagia evaluation and treatment.

The SLP performs a modified barium swallow study (MBSS, CPT 92611) at the hospital radiology suite, identifying mild oral and pharyngeal phase impairment. The SLP develops a treatment plan including:

• Shaker exercise (head-lift exercise)
• Mendelsohn maneuver
• Effortful swallow technique
• Diet modification education
• Compensatory strategies

Patricia attends 2x/week for 8 weeks. SLP charges total approximately $1,400: below the threshold. Medicare pays 80% after her deductible; she has no Medigap and pays the 20% coinsurance out of pocket.

Example 6: Henry, Age 85, Athens: Fall Prevention Occupational Therapy

Henry has had two falls in the past 6 months. His primary care physician at St. Mary's Health Care System in Athens refers him to outpatient OT for fall prevention assessment and intervention.

The OT performs:

• Home environmental assessment (in clinic with photos and family interview)
• Balance and functional mobility testing
• ADL adaptation training
• Adaptive equipment recommendations (grab bars, raised toilet seat, shower chair)
• Caregiver education for his daughter

Henry attends 1x/week for 10 weeks. Total OT charges: approximately $1,500: well below the OT KX threshold. Medicare covers 80% after his $257 deductible. Henry has a Medicare Advantage plan with a $30 per visit copay; the plan covers the visits with no prior authorization required.

The OT also coordinates with home health (separate Part A/B benefit) for a one-time home safety visit. After 10 weeks Henry has implemented home modifications, completed balance training, and has had no further falls. The OT discharges him to an independent home exercise program with family support.

Common Mistakes to Avoid

1. Assuming the therapy cap still exists. The Section 1833(g) cap was permanently repealed February 9, 2018, by the Bipartisan Budget Act of 2018 Section 50202. The KX modifier threshold and targeted medical review threshold are different mechanisms.

2. Believing therapy ends at the KX modifier threshold. Beneficiaries can continue receiving covered therapy above the threshold as long as the therapist documents and attests medical necessity by attaching the KX modifier.

3. Denying maintenance therapy based on lack of improvement. Jimmo v. Sebelius (2013) requires Medicare to cover maintenance therapy when skilled care is needed. Improvement is not required.

4. Failing to obtain physician certification within 30 days. If the plan of care is established by the therapist, it must be reviewed and signed by physician, NP, PA, or CNS within 30 days.

5. Failing to recertify the plan every 90 days. Recertification is mandatory under 42 CFR 410.61; therapy services without current certification are not covered.

6. Confusing the KX threshold with the Part B deductible. The Part B deductible ($257 in 2026) is the first-dollar amount the beneficiary pays each year. The KX threshold (approximately $2,410 in 2026) is a documentation trigger for continued therapy.

7. Forgetting the PTA/COTA payment reduction. Services furnished "in whole or in part" by a PTA or COTA are paid at 85% effective January 1, 2022, with CQ or CO modifier required.

8. Using non-Medicare-credentialed therapists. The PT, OT, or SLP must meet Medicare personnel qualifications: appropriate degree, national examination, state licensure, and (for SLP) the ASHA CCC-SLP or equivalent.

9. Assuming all therapy in a hospital outpatient department is billed the same way. HOPD therapy may be paid under OPPS or MPFS depending on context. Beneficiary cost-sharing may differ.

10. Failing to coordinate Part A vs. Part B for SNF residents. Therapy in a Part A SNF stay is included in the per diem; therapy after Part A days are exhausted (or for non-Part-A residents) is Part B and subject to KX modifier threshold.

11. Failing to recognize that home health therapy is a separate benefit. Therapy delivered under a home health plan of care is paid under HH PPS, not MPFS, and is not subject to the KX modifier threshold.

12. Confusing outpatient with office-based. Outpatient therapy can occur in hospital outpatient departments, freestanding clinics, CORFs, SNF Part B, or limited home situations: not just physician offices.

13. Missing that Medicare Advantage plans must cover therapy at least as comprehensively as Original Medicare. MA plans may use prior authorization, but cannot impose lifetime or annual caps inconsistent with Part B coverage rules.

14. Believing Medicare covers fitness or wellness exercise. Only skilled therapy (requiring PT/OT/SLP professional judgment) is covered. Gym memberships, fitness classes, and personal training are not covered Medicare benefits (though Medicare Advantage plans may offer supplemental fitness benefits like SilverSneakers).

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Does Medicare cover outpatient physical therapy?

Yes. Section 1861(p) of the Social Security Act establishes outpatient physical therapy as a Medicare Part B benefit. Medicare covers PT services that are reasonable and necessary, furnished by qualified personnel, and provided pursuant to a written plan of care. Beneficiaries pay the Part B deductible ($257 in 2026) and 20% coinsurance unless covered by Medigap or Medicare Advantage cost-sharing.

Does Medicare cover occupational therapy?

Yes. Section 1861(g) of the Social Security Act establishes outpatient occupational therapy as a Medicare Part B benefit. The same plan of care, personnel, and medical necessity requirements apply as for PT.

Does Medicare cover speech-language pathology?

Yes. Section 1861(ll) of the Social Security Act, added by the Balanced Budget Act of 1997, establishes speech-language pathology services as a Medicare Part B benefit. SLP covers speech, language, voice, cognitive-communication, dysphagia, and augmentative and alternative communication services.

Is there still a therapy cap on Medicare outpatient rehabilitation?

No. The Section 1833(g) therapy cap was permanently repealed by the Bipartisan Budget Act of 2018 Section 50202, retroactive to January 1, 2018. The KX modifier threshold and targeted medical review threshold are documentation mechanisms, not coverage limits.

What is the KX modifier threshold for 2026?

The KX modifier threshold for 2026 is approximately $2,410 for PT and SLP combined and approximately $2,410 for OT. The threshold updates annually based on the Medicare Economic Index. Beneficiaries can verify the current-year threshold via Medicare.gov or 1-800-MEDICARE.

What does the KX modifier do?

The KX modifier is the provider's written attestation that therapy services above the threshold are reasonable and necessary. The provider attaches the modifier to claim lines for additional therapy beyond the threshold. Coverage continues so long as services remain medically necessary and documented.

What is the targeted medical review threshold?

The targeted medical review (TMR) threshold is $3,000 for PT/SLP combined and $3,000 for OT through CY 2027. Above the TMR threshold, CMS may select specific providers for prepayment or postpayment medical review based on data analysis. Not all claims above $3,000 are individually reviewed.

Does Medicare cover maintenance therapy?

Yes. Under the Jimmo v. Sebelius 2013 federal class action settlement, Medicare cannot deny therapy on the basis that the beneficiary is not improving. Maintenance therapy is covered when skilled services are required. CMS issued clarifying transmittals in 2014 and a court-ordered educational campaign in 2017.

What is the Jimmo settlement?

Jimmo v. Sebelius is a 2013 federal class action settlement that rejected Medicare's prior "improvement standard." Under Jimmo, Medicare coverage of therapy depends on whether skilled services are required, not on whether the patient is improving. The settlement applies to outpatient therapy, home health therapy, and skilled nursing facility therapy.

Who can establish a plan of care for outpatient therapy?

Under 42 CFR 410.61, a plan of care can be established by a physician, nurse practitioner, physician assistant, clinical nurse specialist, or qualified therapist (PT, OT, or SLP). If established by the therapist, the plan must be reviewed and signed by physician, NP, PA, or CNS within 30 days.

How often must the plan of care be recertified?

The plan of care must be recertified at least every 90 days. The physician, NP, PA, or CNS must review and sign the updated plan. Documentation must support continued medical necessity for the recertification period.

Can a PTA or COTA provide my therapy?

Yes, under PT or OT supervision and consistent with state law. However, services furnished "in whole or in part" by a PTA are paid at 85% of the otherwise applicable PT rate effective January 1, 2022, with the CQ modifier required. Parallel rules apply to OT services furnished by a COTA, with the CO modifier required.

Is there a Medicare-recognized SLP assistant?

No. Unlike PT and OT, speech-language pathology services must be furnished by a qualified SLP for Medicare billing. There is no Medicare-recognized SLP assistant role for billing purposes, though some states recognize SLP assistants for other purposes.

What if I have therapy in a hospital outpatient department?

Therapy in a hospital outpatient department (HOPD) is generally billed under Medicare Part B and is subject to the KX modifier threshold and TMR threshold. Payment may be under OPPS or MPFS depending on the specific service and the hospital's billing structure.

What if I am in a skilled nursing facility?

If you are under a Part A SNF stay, therapy is included in the consolidated per diem payment under PDPM and is not separately billable. If you are not under a Part A stay (for example, custodial care residents), therapy is billed under Part B and subject to KX threshold.

Does Medicare cover therapy in my home?

Therapy delivered under a Part A home health episode is covered under the home health benefit and is not subject to the KX threshold. For beneficiaries not under a home health episode, Part B outpatient therapy in the home is available in limited circumstances.

What is a CORF?

A comprehensive outpatient rehabilitation facility (CORF) is a physician-directed, multidisciplinary outpatient rehabilitation provider defined by Section 1861(cc) of the Social Security Act. CORFs provide PT, OT, SLP, social services, psychological services, prosthetic/orthotic services, nursing, drugs, supplies, and respiratory therapy. CORFs are very rare nationally; Georgia has few CORFs, and most outpatient rehab is delivered through hospital outpatient departments and freestanding clinics.

How does Medicare Advantage cover outpatient therapy?

Medicare Advantage plans must cover outpatient PT, OT, and SLP at least as comprehensively as Original Medicare. MA plans may use prior authorization and may charge per-visit copays in lieu of coinsurance. MA plans cannot impose lifetime or annual caps inconsistent with Part B coverage rules.

Do I need a referral for outpatient therapy?

Original Medicare does not require a referral, but a plan of care must be certified by a physician, NP, PA, or CNS. Most Medicare Advantage plans require prior authorization or a referral. State practice laws vary regarding direct access to PT, OT, and SLP. Georgia allows direct access to physical therapy with limitations.

What is LSVT BIG and LOUD?

Lee Silverman Voice Treatment BIG (physical therapy) and LOUD (speech therapy) are evidence-based intensive treatment protocols for Parkinson's disease. The standard protocol is 16 sessions over 4 consecutive weeks (4 sessions per week). LSVT BIG addresses bradykinesia and movement quality; LSVT LOUD addresses hypophonic speech. Medicare covers LSVT services when furnished by certified clinicians under standard outpatient therapy rules.

How are therapy services billed?

Outpatient therapy is billed using CPT codes (with some HCPCS codes for specialized services). PT and OT evaluation codes are 97161 through 97168; SLP evaluation codes include 92521 through 92524. Treatment codes are typically time-based (15-minute units). The CQ modifier is required for PTA-furnished services; the CO modifier is required for COTA-furnished services.

How do I appeal a denial of therapy coverage?

The Medicare appeals process has five levels: redetermination by the Medicare Administrative Contractor (Palmetto GBA in Georgia), reconsideration by the Qualified Independent Contractor, hearing before an Administrative Law Judge, review by the Medicare Appeals Council, and judicial review in federal district court. Strict filing deadlines apply at each level. KEPRO is Georgia's Quality Improvement Organization and handles expedited beneficiary-initiated reviews for certain situations.

Where can I find a qualified therapist in Georgia?

Georgia beneficiaries can find qualified PTs, OTs, and SLPs through major hospital systems (Emory, Piedmont, Wellstar, NGHS, Memorial Health, AU Medical, Atrium Navicent, Phoebe Putney, Grady), national outpatient PT chains (Athletico, ATI, Drayer, Benchmark, Results, Select, Ivy Rehab, Foothills, Pivot), and Medicare provider databases. Always verify state licensure through the Georgia Secretary of State and Medicare enrollment status before scheduling care.

Does Medicare cover fitness programs?

No. Original Medicare does not cover fitness, wellness, or exercise programs that are not skilled therapy. Many Medicare Advantage plans offer supplemental fitness benefits like SilverSneakers, but these are not Original Medicare benefits.

Where can Georgia families get help with therapy questions?

GeorgiaCares (the State Health Insurance Assistance Program) provides free Medicare counseling at 1-866-552-4464. Medicare Rights Center (1-800-333-4114) offers free national counseling. Palmetto GBA (1-877-567-9230) handles Medicare Part B claims for Georgia. Atlanta Legal Aid (404-377-0701) and Georgia Legal Services Program (1-800-498-9469) provide free legal assistance with Medicare appeals for eligible Georgia residents. :::

::: cta Get help understanding your Georgia Medicare outpatient rehabilitation coverage.

Brevy's eldercare guides at brevy.com help Georgia families understand the federal statutory framework for Medicare outpatient therapy, the KX modifier process, Jimmo maintenance therapy rights, and how to find qualified PTs, OTs, and SLPs in Georgia. Below are key contacts for therapy coverage questions, complaints, and appeals.

Medicare and Federal Resources:

• Medicare general inquiries: 1-800-MEDICARE (1-800-633-4227)
• Medicare.gov for plan finder, provider search, and therapy threshold updates
• Palmetto GBA Jurisdiction J (Georgia Part B Medicare Administrative Contractor): 1-877-567-9230
• KEPRO (Georgia Quality Improvement Organization, appeals): 1-844-455-8708
• Social Security Administration (Medicare enrollment): 1-800-772-1213
• HHS Office for Civil Rights: 1-800-368-1019
• HHS Office of Inspector General (fraud hotline): 1-800-447-8477

Georgia State Resources:

• GeorgiaCares (SHIP free Medicare counseling): 1-866-552-4464
• Georgia DCH Medicaid Member Services: 1-866-211-0950
• Georgia State Board of Physical Therapy (license verification): 478-207-2440
• Georgia State Board of Occupational Therapy: 478-207-2440
• Georgia Board of Speech-Language Pathology and Audiology: 478-207-2440

Advocacy and Legal Assistance:

• Medicare Rights Center (national free counseling): 1-800-333-4114
• Center for Medicare Advocacy (Jimmo settlement resources): 1-860-456-7790
• Atlanta Legal Aid Society: 404-377-0701
• Georgia Legal Services Program: 1-800-498-9469

Community and Information Services:

• 211 Georgia: dial 211
• Eldercare Locator: 1-800-677-1116
• VA Benefits: 1-800-827-1000

This guide is informational, not legal or medical advice. Medicare rules and KX modifier thresholds change annually. Always verify current thresholds and coverage with Medicare.gov or 1-800-MEDICARE before making care decisions, and consult a qualified physician, therapist, or benefits counselor for advice on your specific situation. :::