If you’re a physical therapist or clinic owner working with Medicare patients, you’ve probably noticed that things never stay the same for long. And here we are—2025 is in full swing, and with it comes new Medicare billing rules you absolutely need to understand if you want to stay compliant and get paid on time.
There’s no sugarcoating it: Medicare rules can be complex. But that doesn’t mean you have to be overwhelmed by them. In this post, we’re breaking it down so you know exactly what’s changed, what you need to watch for, and how PT Billing can help keep your clinic ahead of the curve.
Why It’s Crucial to Understand Medicare Billing in 2025
Let’s get real—Medicare is one of the largest payers in the physical therapy space. And while it offers a steady flow of patients, it also brings some of the strictest billing requirements.
One small mistake in your claims or documentation can trigger denials, audits, or even clawbacks. That’s not just a headache—it’s a potential revenue hit and a compliance risk. The good news? Understanding Medicare’s expectations upfront puts you in the driver’s seat.
2025 has brought several updates that PTs need to know about. From CPT code changes to updates on the KX modifier and supervision rules, we’ve got you covered.
Medicare and PT: The Anatomy of the Billing Process
Before diving into 2025’s updates, let’s quickly refresh how Medicare billing works for physical therapy.
Medicare Part B typically covers outpatient physical therapy, but it comes with a few strings attached:
- Services must be medically necessary.
- PTs must follow specific coding, documentation, and supervision rules.
- There are therapy thresholds and modifiers involved.
- Enrollment and credentialing with Medicare is required.
- Everything must be timely, accurate, and defensible.
It’s a system that rewards precision—and penalizes sloppiness.
What’s New in 2025? Medicare Changes That Affect PTs
1. CPT Code and Fee Schedule Updates
Each year, CMS adjusts reimbursement rates and updates codes. In 2025, several physical therapy CPT codes have been revalued, and a few new ones have been added for expanded modalities like digital therapeutic monitoring.
You’ll want to double-check the Medicare Physician Fee Schedule (MPFS) for 2025 to see how your most-used codes are reimbursed. Some rates may have dropped slightly, while others increased, depending on service value and utilization.
Link to CMS Fee Schedule:
www.cms.gov/medicare/physician-fee-schedule
2. The KX Modifier Still Matters—Maybe Even More Now
The KX modifier continues to be required when a patient’s therapy services exceed the annual threshold ($2,330 combined for PT and SLP services in 2025). But Medicare has tightened its oversight on justifying medical necessity beyond the cap.
In other words, if you’re using the KX modifier, be ready to prove that the patient still needs skilled therapy. Thorough documentation is your shield.
3. Telehealth for Physical Therapy: Still Alive (For Now)
Temporary telehealth expansions due to COVID were extended again through 2025. That means PTs can still provide and bill Medicare for certain telehealth services, but only if:
- The service qualifies under the approved list
- Audio-visual technology is used
- You’re following the latest telehealth supervision rules
However, Medicare is signaling that these flexibilities might end or evolve in 2026, so don’t get too comfortable.
More on telehealth guidelines:
www.cms.gov/telehealth
4. Supervision Rules for Assistants: Direct vs General
There’s a continued emphasis on appropriate supervision of PTAs. In 2025:
- General supervision remains acceptable in outpatient settings, meaning the PT doesn’t need to be onsite but must be available.
- PTs must still review and cosign notes when required, and all documentation must reflect who performed the service.
5. New G-Codes for Maintenance Therapy
Medicare has introduced new G-codes to differentiate active therapy from maintenance care. This helps clarify what’s reimbursable—and what’s not. Maintenance therapy is still covered under specific conditions, but progress notes and recertifications are essential.
Why Denials Happen with Medicare—and How to Stay Clear
Medicare denials are usually caused by:
- Incomplete or vague documentation
- Exceeding thresholds without proper modifiers
- Missing certifications or recertifications
- Using outdated CPT codes
- Lack of medical necessity
The biggest mistake? Assuming Medicare is just like any other payer. It’s not.
Medicare auditors are trained to look for any deviation from guidelines, so being consistent and detailed is your best protection. And no, templates alone won’t save you. Each visit note needs to reflect individual care and skilled decision-making.
Documentation in 2025: What Medicare Wants to See
To get paid (and stay paid), here’s what your notes need to show:
- The reason the patient needs skilled care
- Objective measures that track progress
- A clear plan of care signed and certified
- Time logs that justify time-based CPT codes
- Proof that the service required a licensed therapist—not just exercise supervision
Medicare is also cracking down on “cloned” notes. If your eval, progress report, and discharge summary all read the same? Expect scrutiny.
Strategies to Stay Compliant (and Get Paid Faster)
1. Regular Medicare Training for Your Team
PTs and front-desk staff need ongoing education. Medicare rules change yearly, and everyone who touches billing or documentation needs to be in the know.
2. Use a Medicare-Specific Checklist
A customized checklist at the point of documentation can save hours in rework later. PT Billing provides these to all our clients—and updates them yearly.
3. Get Ahead with Real-Time Claim Scrubbing
PT Billing’s claim software checks Medicare claims before submission, flagging errors, missing modifiers, and outdated codes. That means fewer denials and faster reimbursement.
4. Stay on Top of Certifications
Ensure initial and recertification of Plans of Care are completed within 30 days of the start and every 90 days thereafter. Use EMR alerts or assign a team member to track deadlines.
5. Conduct Internal Compliance Audits
Don’t wait for a Medicare audit to discover issues. PT Billing runs quarterly audits for our clients to catch documentation gaps, billing errors, and compliance risks before they become problems.
Prevention = Protection
Avoiding billing errors doesn’t just protect your revenue—it protects your license. Compliance issues can lead to:
- Post-payment reviews
- Repayment demands
- Medicare exclusion (yes, that’s a thing)
That’s why prevention is everything. When you partner with experts like PT Billing, you don’t just get claims processed—you get peace of mind that someone is watching your back.
Let PT Billing Keep You Compliant in 2025
Let’s be honest—staying on top of Medicare’s evolving rules is a full-time job. But it doesn’t have to be your job.
PT Billing specializes in physical therapy billing—and we’re locked into Medicare’s latest changes. From real-time eligibility checks to compliant documentation protocols, we help clinics just like yours get paid faster and stay 100% audit-ready.
Don’t wait for a denial or audit to realize you need help. Let’s optimize your billing, together.
Book your free consultation now and let’s make Medicare work for your clinic—not against it.