Physical Therapy Billing · 2026

The PTA CQ Modifier and Plan-of-Care Recert Clock in 2026 Physical Therapy

Three separate deadlines govern a single PT episode, and they never line up on their own. Put them on one clock and none of them ambushes you at the claim edit.

Short answer: append CQ to any line a physical therapist assistant furnishes for more than 10 percent of the service and take the 15 percent payment cut on that line, append KX once the beneficiary crosses the CY2026 Medicare therapy threshold, and recertify the plan of care no later than day 90. Miss the recert and the KX line denies no matter how clean the coding is.

15%

CQ payment reduction

Lines furnished in whole or in part by a PTA pay at 85 percent of the fee schedule under Section 1834(v) of the Social Security Act.

90 days

Recert clock

Medicare requires the plan of care be recertified at least every 90 calendar days, per 42 CFR 424.24 and Benefit Policy Manual Ch. 15.

$3,000

Medical review threshold

The targeted medical review threshold stays fixed at $3,000 through 2027, separate from the annually indexed KX threshold.

One episode, three clocks, laid on a timeline

A representative outpatient PT episode for a total-knee rehab patient. The blue nodes are routine, gold is a decision point that changes the dollars, red is a hard denial trigger. Each event is where the rule fires, not where you first hear about it in an EOB.

Day 0 · Evaluation

PT signs the initial certification

The evaluating physical therapist establishes the plan of care. The certification date starts the 90-day recert clock. Log the exact date the plan is signed, not the date of the first treatment visit.

Set the trigger now: stamp the recert due date at certification so it is visible on every subsequent visit note.

Days 1–30 · Treatment

PTA starts covering visits, CQ enters the picture

When a physical therapist assistant furnishes more than 10 percent of a given timed service, that line carries CQ and pays at 85 percent. The de minimis test is per service, per date, so the same visit can have some CQ lines and some full-rate lines.

Watch: CQ is a line-level decision driven by minutes, not a blanket flag on the claim. APTA guidance walks through the more-than-10-percent de minimis standard unit by unit.

Crossing point · KX threshold

Beneficiary crosses the CY2026 therapy threshold

Once cumulative PT and SLP allowed charges pass the Medicare therapy threshold that CMS updates each year in the CY2026 Physician Fee Schedule (the combined PT and SLP threshold was $2,410 in CY2025 and indexes upward for 2026), every further medically necessary line needs the KX modifier attesting the services are reasonable and necessary.

Compounding: a line can carry both KX and CQ at the same time. KX keeps it payable past the cap, CQ still trims it to 85 percent.

Day 90 · Hard deadline

Recert is due, or the clean claim denies anyway

The plan of care must be recertified by day 90. Coding can be flawless, the KX threshold logic can be perfect, and the line still denies for a lapsed certification. This is the deadline that most often turns a payable episode into rework.

Denial trigger: recert late and the payer treats the intervening dates as furnished under an expired plan of care.

Day 91+ · New cycle

Fresh 90-day clock, same CQ and KX rules ride along

Recertification restarts the recert clock but changes nothing about CQ or KX. If the PTA is still covering visits, CQ continues line by line, and every line past the threshold still needs KX. If cumulative charges approach $3,000, the episode also enters the targeted medical review window.

The CQ de minimis test, in one screen

The only question that decides whether CQ attaches to a timed line: did the PTA furnish more than 10 percent of that service on that date.

PTA share is 10% or less

≤10%

No CQ on that line
Line pays at 100 percent of the fee schedule
Document the minute split so the de minimis call is defensible on audit

PTA share is more than 10%

>10%

Append CQ to that line
Line pays at 85 percent (15 percent reduction)
Applies per service, per date, so mixed visits are normal

The three rules do not overlap, so keep them straight

CQ, KX, and recertification answer different questions. Treating them as one policy is how episodes leak.

Rule	Question it answers	Trigger	What it costs if missed
CQ modifier	Who furnished the service	PTA furnishes more than 10 percent of a timed line	Overpayment exposure and takeback if CQ is omitted; the reduction is owed regardless
KX modifier	Is the patient past the cap and still medically necessary	Cumulative PT and SLP charges cross the CY2026 threshold	Line denies as exceeding the therapy threshold
POC recertification	Is there a current physician-certified plan of care	90 calendar days since the last certification	Line denies for lapsed certification even when coding is clean
Targeted medical review	Should this high-cost episode get extra scrutiny	Cumulative charges reach $3,000 (fixed through 2027)	Documentation review, delayed payment, higher denial risk

The 2026 guidelines this rests on

Cited by name so your team can pull the primary source, not a summary of a summary.

CMS · CY2026 PFS Final Rule

Sets the annually indexed Medicare outpatient therapy threshold (the KX threshold) for PT and SLP combined and for OT separately. The CY2025 combined PT and SLP figure was $2,410; confirm the 2026 value in the published final rule before you hard-code it.

Section 1834(v), Social Security Act

Establishes the 15 percent payment reduction for outpatient therapy furnished in whole or in part by a PTA (CQ) or OTA (CO), and the more-than-10-percent de minimis standard.

42 CFR 424.24 · Benefit Policy Manual Ch. 15

Requires physician or NPP certification of the plan of care and recertification at least every 90 days, or sooner when the plan is significantly modified.

APTA · Payment and Regulatory Guidance

Practical guidance on applying the CQ modifier and the de minimis calculation unit by unit, and on documenting the PTA minute split for audit defense.

The rules are knowable. The calendar is what beats clinics.

ASP-RCM builds the CQ minute check, the KX threshold tracker, and the 90-day recert alert into your physical therapy billing workflow so each one surfaces on the visit before it becomes a denial, not on the remittance after. Fewer takebacks, cleaner threshold lines, no episodes lost to a lapsed plan of care.

Put your PT episodes on one clock →

Threshold dollar figures are set annually in the CMS Physician Fee Schedule. Confirm the current CY2026 value against the published final rule before configuring claim edits. This page is billing operations guidance, not legal or coverage advice.