97110

🏋️ CPT 97110 — Therapeutic Exercises to Develop Strength and Endurance, Range of Motion and Flexibility

Quick Reference

wRVU: 0.45 (per 15-min unit) | Global Period: 000 (same day) | Assistant Payable: ❌ No | Bilateral Indicator: 1

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📋 Clinical Description

CPT 97110 describes skilled therapeutic exercise performed by — or under the direct supervision of — a licensed physical therapist (PT), occupational therapist (OT), or other qualified practitioner, targeting one or more anatomic areas to improve muscular strength, endurance, range of motion (ROM), and flexibility. The code is time-based and billed in 15-minute increments; documentation must capture the total timed minutes spent in direct one-on-one contact to support each unit reported. It is distinguished from its close sibling 97530 (therapeutic activities) in that 97110 involves targeted, repetitive exercise movements (e.g., resistance training, ROM drills, stretching protocols), whereas 97530 involves functional, task-oriented activities simulating daily living.

Conditions driving 97110 are broadly those producing deficits in strength, endurance, or mobility — including post-surgical deconditioning, neurological weakness, musculoskeletal injury, and chronic disease-related functional decline. When the underlying etiology is a neurological condition such as G83.4 (cauda equina syndrome) or G54.4 (lumbosacral root disorders), therapeutic exercise targets the downstream neuromuscular deficit; the primary diagnosis code documents the causative condition, not just the symptom.

This procedure may be performed in the following clinical contexts:

• Post-surgical rehabilitation (orthopedic) — Prescribed following joint replacement, spinal fusion, or fracture fixation to restore periarticular strength and functional ROM; exercises are progressive and protocol-driven.
• Neurological deficit rehabilitation — Used following stroke, spinal cord injury, or compressive neuropathy (e.g., cauda equina syndrome) to recruit and strengthen weakened motor units through targeted resistance and ROM work.
• Chronic musculoskeletal pain with deconditioning — Indicated when documented muscle weakness or flexibility deficits accompany chronic low back pain, degenerative joint disease, or fibromyalgia; medical necessity rests on functional deficit, not pain alone.
• Inpatient rehabilitation facility (IRF) admission — Provided as part of the intensive therapy program (minimum 3 hours/day) required for IRF level of care; profee billing by the supervising physician is separate from the facility’s IRF-PPS payment.
• Post-immobilization or bed rest deconditioning — Following prolonged hospitalization, cast immobilization, or medically required inactivity, therapeutic exercise rebuilds baseline strength and ROM to support discharge goals.

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🔬 Anatomical & Procedural Considerations

Exercise Type / Modality	Mechanism / Technique	Key Notes / Coding Impact
Resistance / Strengthening Exercise	Progressive loading applied to target muscle groups via free weights, resistance bands, weight machines, or manual resistance; therapist adjusts load to promote hypertrophy and endurance	Must document: specific muscle groups targeted, resistance level, sets/reps, and one-on-one time; therapist must be in direct contact (not supervisory) for the timed period
Range of Motion (ROM) Exercise	Active, active-assisted, or passive joint movement through the available arc to maintain or restore joint mobility; may be combined with stretching protocols	Active ROM performed by the patient WITH therapist guidance counts toward timed units; passive ROM performed entirely by the therapist without patient participation maps to 97124 (massage/manipulation) — do not commingle
Flexibility / Stretching	Static, dynamic, or proprioceptive neuromuscular facilitation (PNF) stretching targeting shortened musculotendinous structures	Document: specific muscles stretched, duration of hold, technique used; PNF requires therapist direct contact and active patient effort — fully supports 97110
Aquatic Therapeutic Exercise	Resistance and ROM exercise performed in a therapeutic pool using water’s buoyancy and resistance properties	May be reported as 97113 (aquatic therapy with therapeutic exercises) instead of 97110 when performed in a pool; do not report 97110 and 97113 for the same area in the same session
Functional Strengthening / Neuromuscular Re-education Overlap	Exercises designed to retrain motor control and coordination (e.g., balance board squats, PNF patterns) may overlap 97110 and 97112	Report the code that best reflects the primary therapeutic goal: 97110 if strengthening/ROM is primary; 97112 if neuromuscular re-education is primary; do not report both for the same time block

Clinical Pearl The 8-minute rule

(CMS) governs unit billing: a single 15-minute unit requires ≥ 8 minutes of direct one-on-one therapeutic contact. For multiple timed codes in the same session, total timed minutes are divided by 15 and any remaining minutes ≥ 8 count as an additional unit. Document start and stop times — or total timed-service minutes — in every therapy note. Missing time documentation is the single leading cause of TPE (Targeted Probe and Educate) audit denial for 97110.

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✅ Procedure Includes

• Pre-exercise baseline assessment of strength, ROM, and patient tolerance at the start of each session
• Direct one-on-one skilled therapeutic contact by the qualified clinician for the entire timed period
• Active, active-assisted, or passive exercise applied to the targeted anatomic region(s)
• Verbal cueing, manual guiding, and real-time technique correction by the therapist throughout the session
• Progressive adjustment of resistance or ROM parameters based on patient response within the session
• Documentation of the specific exercises performed, targeted muscle groups or joints, resistance levels, repetitions/sets, and total direct contact time

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❌ Excludes / Do Not Report Together

Code	Description	Relationship to 97110
97530	Therapeutic activities, direct (one-on-one) patient contact, each 15 minutes	Report 97530 when the intervention is functional, task-oriented, and simulates ADL/IADL performance; 97110 targets isolated strength/ROM — the distinction is exercise vs. activity; report one or the other per time block, not both for the same minutes
97112	Neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and proprioception, each 15 minutes	When therapeutic exercise also addresses neuromuscular control, select the code reflecting the primary therapeutic intent; do not split the same time block between 97110 and 97112
97113	Aquatic therapy with therapeutic exercises, each 15 minutes	When therapeutic exercise is performed in a pool, 97113 is the correct code; do not report 97110 and 97113 for the same area in the same session
97124	Massage, including effleurage, petrissage, and/or tapotement (stroking, compression, percussion), each 15 minutes	Passive ROM performed entirely by the therapist without active patient participation is not 97110; if the dominant service is passive tissue mobilization, 97124 or 97140 is more appropriate
97140	Manual therapy techniques (e.g., mobilization/manipulation, manual lymphatic drainage, manual traction), each 15 minutes	Joint mobilization and manual traction are not therapeutic exercises; report 97140 separately if a distinct, separately documented manual therapy service is provided — NCCI allows same-day billing with modifier -59 if distinct time and body area are documented
E/M codes (992xx / 920xx)	Office visit, any level	Separately reportable only when modifier -25 is appended to the E/M code, documenting a significant, separately identifiable E/M service beyond the routine pre-procedure assessment

Bundling Alert — Global Period is 000, Not 010 or 090

CPT 97110 carries a 000-day global period, meaning no post-procedure follow-up is bundled — each session is billed independently. There is no global window to track across dates of service. However, the most critical bundling risk is intra-session time overlap: CMS’s 8-minute rule requires that the same minutes cannot be counted toward two timed codes simultaneously. Reporting 97110 and 97530 for overlapping time is a top CMS fraud vector for therapy providers and a leading cause of RAC and TPE audit findings.

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🌳 Code Tree — Medicine: Physical Medicine and Rehabilitation — Therapeutic Procedures

97010-97799  Physical Medicine and Rehabilitation
│
├── 97010-97028  Modalities (Supervised)
│   ├── 97010  Hot or cold packs
│   ├── 97012  Traction, mechanical
│   ├── 97014  Electrical stimulation (unattended)
│   ├── 97016  Vasopneumatic devices
│   ├── 97018  Paraffin bath
│   ├── 97022  Whirlpool
│   ├── 97024  Diathermy
│   └── 97028  Ultraviolet therapy
│
├── 97032-97039  Modalities (Requiring Constant Attendance)
│   ├── 97032  Electrical stimulation (manual), each 15 min
│   ├── 97033  Iontophoresis, each 15 min
│   ├── 97034  Contrast baths, each 15 min
│   ├── 97035  Ultrasound, each 15 min
│   └── 97039  Unlisted modality, each 15 min
│
├── 97110-97546  Therapeutic Procedures (Direct One-on-One)
│   ├── ▶▶ 97110 ◀◀  Therapeutic exercises — strength, endurance, ROM, flexibility  ← YOU ARE HERE  (Global: 000)
│   ├── 97112  Neuromuscular reeducation  (Global: 000)
│   ├── 97113  Aquatic therapy with therapeutic exercises  (Global: 000)
│   ├── 97116  Gait training  (Global: 000)
│   ├── 97129  Therapeutic interventions — cognitive function  (Global: 000)
│   ├── 97150  Therapeutic procedure(s), group (2 or more individuals)  (Global: 000)
│   ├── 97530  Therapeutic activities — functional performance  (Global: 000)
│   ├── 97533  Sensory integrative techniques  (Global: 000)
│   ├── 97535  Self-care/home management training  (Global: 000)
│   └── 97542  Wheelchair management training  (Global: 000)
│
└── 97597-97799  Active Wound Care / Other PM&R Procedures

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💰 RVU & Reimbursement Profile

Component	Value
Work RVU (wRVU)	0.45 per 15-minute unit (verify against current CMS MPFS for applicable year)
Global Period	000 (same day)
Bilateral Indicator	1 — Subject to standard bilateral reduction rules; however, bilateral indicator is largely theoretical for timed therapy codes; laterality is typically addressed through documentation of body region, not modifier -50
Assistant Surgeon	❌ Not payable
Co-Surgeon	❌ Not applicable
Team Surgery	❌ Not applicable
PC/TC Split	❌ No — procedure code only (Indicator 0)
Modifier -51 Exempt	No — subject to multiple procedure rules when reported with other therapy codes
Anesthesia	No separate anesthesia; procedure performed with patient awake and actively participating

Therapy Cap & KX Modifier

Medicare applies a financial limitation (therapy cap) to outpatient PT and OT services under Part B. When the documented clinical need exceeds the cap threshold, the -KX modifier must be appended to 97110 to attest that the services are medically necessary and that the provider has documentation on file supporting the exception. Failure to append -KX when billing above the cap will result in claim denial. For 2025, the combined PT/SLP cap is approximately $2,410 and the OT cap is the same — verify annually via CMS MLN updates.

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🏷️ Modifier Reference

Modifier	Name	When to Apply
-GP	Services Delivered Under Outpatient PT Plan of Care	Required on all PT claims for Medicare Part B; identifies the supervising discipline
-GO	Services Delivered Under Outpatient OT Plan of Care	Required on all OT claims for Medicare Part B
-GN	Services Delivered Under Outpatient SLP Plan of Care	Required on all SLP claims; rare with 97110 but applicable in select neuromuscular contexts
-KX	Requirements Specified in Medical Policy Have Been Met	Required when billing above the Medicare therapy cap threshold; attest that documentation of medical necessity is on file
-CQ	Services Furnished in Whole or in Part by a PTA	Required when a physical therapist assistant provides any portion of the 97110 service; triggers 20% payment reduction under PAMA 2018
-CO	Services Furnished in Whole or in Part by a COTA	Required when a certified occupational therapy assistant provides any portion of the service; triggers 20% payment reduction
-59	Distinct Procedural Service	When 97110 is billed same session as another therapy code (e.g., 97140) for a distinct body area or distinct time block; required to override NCCI bundling edits
-25	Significant, Separately Identifiable E/M	Applied to the E/M code — not 97110 — when a physician/NPP performs a substantive evaluation beyond routine pre-therapy assessment on the same date; document separate medical decision-making
-52	Reduced Services	Procedure partially completed — document reason (e.g., patient fatigue, pain) and time actually performed
-53	Discontinued Procedure	Procedure stopped due to patient safety concern; document clinical reason thoroughly

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🩺 Common ICD-10-CM Pairings

Musculoskeletal — Weakness, Deconditioning, and Low Back Conditions

ICD-10 Code	Description	HCC?	Clinical Notes
M62.81	Muscle weakness (generalized)	❌ No	Use when generalized weakness is the primary documented deficit driving therapy; query for specific etiology (neurologic, post-surgical, disuse) when present
M54.50	Low back pain, unspecified	❌ No	Least specific — use only when provider has not documented type; query for vertebrogenic, radiculopathy, or discogenic etiology
M54.51	Vertebrogenic low back pain	❌ No	When structural vertebral pathology is the documented source; appropriate for core stabilization and lumbar strengthening programs
M54.59	Other low back pain	❌ No	When low back pain is documented but does not fit vertebrogenic or radicular categories
M54.41	Lumbago with sciatica, right side	❌ No	When radicular symptoms accompany lumbar weakness; supports therapeutic exercise targeting lumbar and lower extremity musculature
M54.42	Lumbago with sciatica, left side	❌ No	Left-sided radicular presentation

Neurological — Weakness and Functional Deficit from Neural Origin

ICD-10 Code	Description	HCC?	Clinical Notes
G83.4	Cauda equina syndrome	✅ HCC 72	When therapeutic exercise addresses lower extremity weakness and ROM deficits from cauda equina involvement; sequence the cauda equina code first; the exercise addresses the downstream functional deficit
G54.4	Lumbosacral root disorders, NEC	❌ No	When root-level compression produces focal weakness and ROM restriction requiring therapeutic exercise; distinct from peripheral neuropathy
G35.D	Multiple sclerosis	✅ HCC 77	High-value HCC; therapeutic exercise for MS-related spasticity, weakness, and ROM limitation; document specific functional deficits
I69.351	Hemiplegia/hemiparesis following cerebral infarction, right dominant	✅ HCC 103	Post-stroke strengthening; sequence the late effect code; document motor deficits and goals
I69.354	Hemiplegia/hemiparesis following cerebral infarction, left non-dominant	✅ HCC 103	Left non-dominant post-stroke presentation
G82.20	Paraplegia, unspecified	✅ HCC 70	When therapeutic exercise targets preserved upper or lower extremity function in SCI patients; query for complete vs. incomplete and level

Post-Surgical and Orthopedic Rehabilitation

ICD-10 Code	Description	HCC?	Clinical Notes
Z96.641	Presence of right artificial hip joint	❌ No	Post-THA rehabilitation; sequence the rehabilitation diagnosis (weakness, ROM limitation) first if documented; Z96 codes are additional diagnoses supporting context
Z96.642	Presence of left artificial hip joint	❌ No	Left-side THA rehabilitation context
M17.11	Primary osteoarthritis, right knee	❌ No	Conservative management with therapeutic exercise before or instead of surgical intervention
M17.12	Primary osteoarthritis, left knee	❌ No	Left knee OA — conservative therapeutic exercise management
S72.001A	Fracture, unspecified part of neck of right femur, initial encounter	❌ No	Acute phase rehabilitation post-hip fracture; confirm fracture status (initial vs. subsequent) and document if ORIF preceded therapy

Underlying Etiology / Complication Codes

ICD-10 Code	Description	HCC?	Clinical Notes
E11.40	Type 2 diabetes mellitus with diabetic neuropathy, unspecified	✅ HCC 18	When diabetic peripheral neuropathy produces documented weakness or ROM deficit driving therapeutic exercise; sequence diabetes complication code per ICD-10-CM guidelines
Z87.39	Personal history of other musculoskeletal disorders	❌ No	Additional diagnosis supporting clinical context in chronic recurrent musculoskeletal conditions; not a primary coding driver

Coding Specificity Reminder

The most common specificity gap with 97110 pairings is laterality and etiology. For neurological conditions driving therapeutic exercise (e.g., post-stroke hemiplegia, cauda equina, MS), the underlying condition code must be as specific as possible — dominant vs. non-dominant side, complete vs. incomplete, type and stage. For musculoskeletal codes, right vs. left is required at most code levels. Query the provider whenever laterality, etiology, or severity level is absent from the documentation — “muscle weakness” without a documented cause may leave an HCC on the table.

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🏥 MS-DRG Considerations (Inpatient)

Inpatient Coding Reminder

CPT 97110 is reportable in the inpatient setting by the supervising physician or qualified NPP for profee billing. In an inpatient rehabilitation facility (IRF), therapeutic exercise is a core component of the required intensive therapy program, but the facility’s reimbursement is driven by the IRF-PPS Case Mix Group (CMG) — not by individual CPT codes. The CMG is determined by the patient’s functional impairment level (IRF-PAI scoring via FIM™ instrument), primary diagnosis, age, and comorbidities. The profee physician bills 97110 separately under Part B. In an acute inpatient hospital, therapy services may also be reported under Part B; the associated DRG assignment is driven entirely by the principal diagnosis and CC/MCC tier — not by 97110 itself. When 97110 is provided during an acute stay for a high-value principal diagnosis (e.g., G83.4 Cauda Equina Syndrome), the DRG will reflect MDC 01 (Diseases and Disorders of the Nervous System) with grouping influenced by CC/MCC tier.

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🔧 ICD-10-PCS Equivalents (Inpatient Facility Coding)

ICD-10-PCS F-section

(Physical Rehabilitation and Diagnostic Audiology) codes are assigned by the inpatient facility coder — not the profee coder. When therapeutic exercise (97110) is provided during an inpatient stay, the facility assigns F07-series codes. These codes do not directly influence MS-DRG grouping in the acute setting but are required for IRF data capture and UDSMR/IRF-PAI reporting. Root operation selection depends on whether the therapy targets motor function, musculoskeletal function, or ROM specifically.

PCS Code	Full Description	Applicable Modality
F07L00Z	Physical Rehabilitation, Motor Treatment, Musculoskeletal System — Upper Extremity, No Device, No Qualifier	Upper extremity strengthening / ROM — standard
F07L0ZZ	Physical Rehabilitation, Motor Treatment, Musculoskeletal System — No Qualifier	General therapeutic exercise, unspecified region
F07M00Z	Physical Rehabilitation, Motor Treatment, Musculoskeletal System — Lower Extremity, No Device, No Qualifier	Lower extremity strengthening / ROM
F07Z0ZZ	Physical Rehabilitation, Motor Treatment, None — No Device, No Qualifier	Generalized therapeutic exercise without site specification

PCS Character Analysis — F07L00Z

Position	Character	Value	Definition
1	Section	F	Physical Rehabilitation and Diagnostic Audiology
2	Section Qualifier	0	Rehabilitation
3	Root Type	7	Motor Treatment (application of techniques to improve, augment, or compensate for motor function deficits)
4	Body System / Region	L	Musculoskeletal System — Upper Extremity
5	Type Qualifier	0	Therapeutic Exercise
6	Equipment	Z	None
7	Qualifier	Z	No Qualifier

PCS Root Type: Motor Treatment (7) vs. Therapeutic Exercise Type Qualifier (0)

• Use Root Type 7 (Motor Treatment) with Type Qualifier 0 (Therapeutic Exercise) when the goal is restoration of strength, endurance, ROM, or flexibility through exercise — this is the direct PCS parallel to CPT 97110.
• Use Root Type 6 (Motor Function) when the goal is assessment rather than treatment — this maps to diagnostic/evaluative procedures, not 97110.
• When therapeutic exercise addresses both upper and lower extremities in the same session, assign separate PCS code lines for each body region — PCS does not combine multiple regions into a single code the way CPT 97110 can cover “one or more areas.”

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📝 Coding Examples

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Example 1 — Inpatient Hospital: Therapeutic Exercise for Cauda Equina Syndrome, Consulting PM&R Attending

Clinical Scenario: A 58-year-old male admitted to the acute care hospital for L4-L5 disc herniation with documented cauda equina syndrome (G83.4) undergoes emergent decompression by the neurosurgery service. On post-op day 2, PM&R is consulted for inpatient rehabilitation. The PM&R attending evaluates the patient and prescribes a therapeutic exercise program. The therapist provides 30 minutes of direct one-on-one therapeutic exercise targeting bilateral lower extremity strengthening and hip flexor ROM. The therapy note documents: “30 minutes direct therapeutic exercise — bilateral LE strengthening with resistance bands (3 sets × 10 reps, green band), active-assisted hip flexion ROM bilaterally, therapist in direct contact throughout. Patient tolerated session with moderate fatigue.” The PM&R attending co-signs and bills for the medically directed service.

Field	Code	Rationale
CPT	97110 × 2 units	30 minutes of direct therapeutic exercise = 2 × 15-minute units; document supports direct one-on-one contact for full timed period
PDx	G83.4	Cauda equina syndrome — principal diagnosis driving the inpatient admission and the rehabilitation consultation; HCC 72 — capture is critical

Note

The PM&R attending’s profee claim for 97110 is submitted under Part B separately from the facility’s DRG-based inpatient claim. The facility coder will assign a PCS F07-series code for the therapeutic exercise. Do not append GP/GO modifiers in the inpatient acute setting — those are specific to outpatient Part B therapy claims. Ensure the consultation note documents the attending’s direct supervision or personal performance of the medically directed service per CMS incident-to rules for inpatient settings.

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Example 2 — Outpatient Hospital: Therapeutic Exercise with Same-Day Manual Therapy, Post-Lumbar Fusion

Clinical Scenario: A 65-year-old female, 6 weeks post-L3-L5 posterior spinal fusion, presents to the outpatient hospital-based physical therapy clinic. The supervising PT provides 30 minutes of therapeutic exercise (bilateral LE strengthening, lumbar stabilization, hip abductor ROM — documented with start/stop times) and then 15 minutes of manual therapy (lumbar joint mobilization, grade III-IV Maitland technique to L3-L5 segments) to a distinct spinal segment. Total documented timed therapy: 45 minutes. The treating PT holds a separate plan of care from the orthopedic surgeon.

Field	Code	Rationale
CPT 1	97110-GP × 2 units	30 minutes therapeutic exercise; GP = outpatient PT plan of care; 2 units per 8-minute rule
CPT 2	97140-GP-59	15 minutes manual therapy; -59 required to override NCCI edit bundling 97140 with 97110; distinct service (joint mobilization vs. exercise), separate documented time block
PDx	M54.51	Vertebrogenic low back pain — the operative-level structural diagnosis driving post-fusion therapeutic exercise; more specific than M54.50
SDx	Z96.82	Status post spinal fusion — additional diagnosis providing post-surgical clinical context

Warning

NCCI bundles 97110 and 97140 when billed together. Modifier -59 (or X-modifier as appropriate) must be appended to 97140 and the therapy note must document separate time blocks and a distinct therapeutic service for each code — overlapping time attribution is the leading audit finding in this billing pattern. Some MACs prefer XS (separate structure) over 59 — verify your MAC’s current guidance.

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Example 3 — IRF Setting: Therapeutic Exercise for Post-Stroke Hemiplegia, Billing Above Therapy Cap

Clinical Scenario: A 72-year-old female is admitted to an inpatient rehabilitation facility following left MCA ischemic stroke with resultant right hemiplegia (dominant side). She is 3 weeks post-stroke and meets IRF admission criteria. The PM&R attending directs the therapy team. On a given day, the PT provides 45 minutes of direct therapeutic exercise targeting right upper extremity strengthening (shoulder, elbow, wrist/hand), right lower extremity ROM and quadriceps strengthening. The treating PT is a licensed PT (not a PTA). Medicare Part B outpatient therapy cap threshold has already been exceeded for this benefit period. Therapy note documents start/stop times and total 45 minutes direct contact.

Field	Code	Rationale
CPT	97110-GP-KX × 3 units	45 minutes = 3 units; GP = PT plan of care; KX = therapy cap threshold exceeded, medical necessity documentation on file attesting to continued need
PDx	I69.351	Hemiplegia/hemiparesis following cerebral infarction, right dominant side — HCC 103; most specific post-stroke sequela code; sequences the late-effect neurological deficit driving therapeutic exercise
SDx	I63.512	Cerebral infarction due to unspecified occlusion or stenosis of left middle cerebral artery — documents the causative stroke for clinical completeness and IRF-PAI accuracy

-KX modifier reminder:

The -KX modifier is an attestation — it certifies that the documentation in the medical record supports the medical necessity exception to the therapy cap. Appending -KX without the supporting documentation on file creates False Claims Act exposure. In IRF settings, the IRF-PAI functional assessment and the physician’s plan of care serve as the primary supporting documentation. Also note: if a PTA had provided any portion of this session, modifier -CQ would be required and a 20% payment reduction would apply — document PT vs. PTA delivery for every timed unit.

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⚠️ Common Coding Pitfalls

• Insufficient time documentation: The single most common TPE audit denial for 97110 is a therapy note that documents the exercises performed but omits start/stop times or total timed-service minutes. CMS requires documentation of the total timed minutes for each timed code in each session. A note stating “therapeutic exercise performed” without time documentation will not support any unit of 97110, regardless of how detailed the exercise description is.

• Billing 97110 and 97530 for the same time block: These two codes are the most commonly co-billed therapy pair and the most scrutinized by RAC auditors and MACs. 97110 targets isolated muscle strengthening, ROM, and flexibility; 97530 targets functional, task-oriented activities. Reporting both for overlapping minutes violates CMS’s timed code rules. Each time block may only be attributed to one timed code. Splitting a single 30-minute exercise session into 15 minutes of 97110 and 15 minutes of 97530 is appropriate only if the two services are genuinely distinct in nature AND time.

• Omitting -KX when billing above the therapy cap: Medicare will automatically deny 97110 claims exceeding the therapy cap threshold if -KX is absent. The -KX modifier is not optional once the cap is exceeded — it is a required attestation that must accompany every timed therapy code above the cap. Failure to append -KX results in non-covered service denials that cannot be retrospectively corrected without rebilling.

• PTA/COTA modifier omission (-CQ/-CO): Since January 1, 2022, CMS requires -CQ on PT claims and -CO on OT claims when a PTA or COTA provides any portion of the service. Omission results in incorrect payment (100% instead of the required 80%) and creates overpayment liability subject to recoupment. Build a workflow to verify treating clinician credential (PT vs. PTA) for every timed service line before claim submission.

• Defaulting to unspecified ICD-10-CM without querying: Pairing 97110 with M62.81 (generalized muscle weakness) when the documentation contains clear evidence of a neurological etiology (e.g., post-stroke hemiplegia, cauda equina, MS) leaves high-value HCCs uncaptured. The ICD-10-CM code should reflect the most specific underlying condition driving the functional deficit. Query the physician when weakness, ROM limitation, or functional deficit is documented without an explicit etiology — “weakness, etiology unspecified” is a query trigger, not a final coding answer.

• Applying GP/GO modifiers in the acute inpatient setting: Modifiers -GP, -GO, and -GN are outpatient Part B therapy modifiers — they are required on outpatient claims billed under Part B. They are not applied on inpatient acute care facility claims (inpatient Part A) or on profee claims for services provided during an acute inpatient stay. Applying GP to an inpatient profee claim for a PM&R attending directing 97110 in the acute hospital is an improper modifier use that can trigger claim edits or denials.

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📎 Sources

¹ AMA CPT 2025 Professional Edition · ² CMS 2025 Medicare Physician Fee Schedule Final Rule (CMS-1807-F) · ³ CMS RVU25A Relative Value Files · ⁴ NCCI Policy Manual Chapter 11 (Physical Medicine), CMS 2024-2025 · ⁵ ICD-10-CM Official Guidelines for Coding and Reporting FY2025 · ⁶ ICD-10-PCS Official Guidelines for Coding and Reporting FY2025 · ⁷ CMS MLN Matters SE1720 — Outpatient Therapy Services and the Therapy Cap · ⁸ CMS Medicare Benefit Policy Manual, Chapter 15 — Covered Medical and Other Health Services (Therapy Services) · ⁹ AAPC Physical Medicine Coding Guide 2025 · ¹⁰ Protecting Access to Medicare Act (PAMA) 2018 — PTA/COTA Payment Reduction Rules · ¹¹ CMS IRF-PPS Overview and IRF-PAI Training Manual FY2025 · ¹² Novitas Solutions (MAC Jurisdiction H/L) — Physical and Occupational Therapy LCD L33688