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Physical Therapy Caseload and Revenue Calculator

Project PT practice revenue from weekly patient visits, units per visit under the CMS 8-Minute Rule, and 2026 Medicare and commercial reimbursement rates by CPT code including 97110, 97112, 97140, and 97530. Includes therapy threshold tracking and assistant modifier impact.

Primary CPT Code

Payer Type

2026 conversion factor $33.4009. National GPCI 1.0 rates shown; locality adjusts the rate.

Units per Visit

8-Minute Rule: 1 unit = 8 to 22 min, 2 = 23 to 37, 3 = 38 to 52, 4 = 53 to 67.

Visits per Week

Weeks per Year

PTA / OTA Service? (CQ / CO modifier)

Medicare applies a 15% reduction to services furnished in whole or in part by a PTA or OTA.

Your Results

Select a CPT code and payer, then click project.

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Introduction

Physical therapy revenue is a function of units, not visits, and units are governed by the CMS 8-Minute Rule. One unit of a timed CPT code like 97110 requires at least 8 minutes of direct one-on-one care, and total billable units follow the total timed minutes across the whole session: 8 to 22 minutes is 1 unit, 23 to 37 is 2, 38 to 52 is 3, and 53 to 67 is 4. The 2026 Medicare Physician Fee Schedule sets a conversion factor of $33.4009, with 97110 paying about $30.10 per unit at the national GPCI of 1.0. Commercial payers reimburse $40 to $65 per unit for 97110, and workers compensation often pays $45 to $80. The 2026 PT and SLP combined therapy threshold is $2,330 per patient, above which the KX modifier is required and claims may trigger targeted medical review. PTA services under a CQ or CO modifier take a 15% reduction. This calculator projects revenue from units per visit, visits per week, and the 2026 rate by CPT code and payer type.

What This Calculator Does

This tool projects annual revenue for a physical therapy practice. You select a primary CPT code (97110, 97112, 97116, 97140, 97530, 97535, or evaluation codes 97161 to 97163), a payer type (Medicare, commercial, workers comp, or cash-pay), the units per visit, visits per week, and weeks per year. The calculator applies the 2026 Medicare rate or commercial rate by CPT code, adjusts for the PTA/OTA 15% reduction if selected, computes revenue per visit, weekly revenue, and annual revenue, and flags the therapy threshold status. It shows the 8-Minute Rule minute requirement for the chosen unit count.

The Formula

Annual Revenue = Revenue per Visit x Visits per Week x Weeks per Year | Revenue per Visit = Per Unit Rate x Units per Visit | Per Unit Rate = CPT Base Rate x Payer Multiplier x (0.85 if PTA / OTA, else 1.0) | 8-Minute Rule: 1 unit = 8 to 22 min, 2 = 23 to 37, 3 = 38 to 52, 4 = 53 to 67

The CPT base rate is the 2026 Medicare Physician Fee Schedule rate at GPCI 1.0, or the commercial benchmark rate. The payer multiplier is 1.0 for Medicare (uses the MPFS rate directly), approximately 1.7 for commercial, 2.2 for workers comp, and 1.5 for cash-pay. The PTA/OTA reduction of 15% applies when a physical therapist assistant or occupational therapy assistant furnishes the service in whole or in part, under the CMS 2022 fee schedule final rule, using the CQ or CO modifier. The 8-Minute Rule determines billable units from total timed minutes: 8 to 22 minutes is 1 unit, 23 to 37 is 2, 38 to 52 is 3, and 53 to 67 is 4. The 2026 therapy threshold of $2,330 for PT and SLP combined triggers KX modifier requirements and potential targeted medical review.

Step-by-Step Example

Select the primary CPT code

A PT practice billing mostly therapeutic exercise selects 97110, which loads the 2026 Medicare rate of $30.10 per unit.

Choose the payer type

Selecting Medicare applies the MPFS rate directly. Selecting Commercial applies a 1.7x multiplier, making 97110 about $50 per unit.

Enter units and volume

3 units per visit, 40 visits per week, 48 weeks per year. Under the 8-Minute Rule, 3 units requires at least 38 minutes of timed service.

Review the projection

Medicare: $30.10 x 3 = $90.30 per visit. Weekly: $90.30 x 40 = $3,612. Annual: $3,612 x 48 = $173,376. Commercial at $50/unit would project about $288,000.

Real-World Use Cases

PT Practice Revenue Forecasting

A PT clinic owner projects annual revenue by CPT code and payer mix to set staffing levels, rent, and equipment budgets, and to compare Medicare-heavy versus commercial-heavy payer strategies.

8-Minute Rule Compliance Check

A billing manager verifies that the units billed per visit match the timed minutes documented, using the 8-Minute Rule thresholds to prevent denials from insufficient documentation.

Therapy Threshold Monitoring

A PT practice tracks per-patient annual charges against the $2,330 therapy threshold to apply the KX modifier on time and prepare documentation for potential targeted medical review.

Common Mistakes to Avoid

Billing every payer as if it were Medicare. Many commercial payers use the AMA Rule of Eights instead of the CMS 8-Minute Rule, counting each timed service separately against the 8-minute threshold rather than totaling the session. Billing every payer with the CMS method is a quiet, recurring source of denials and underbilling.
Ignoring the PTA/OTA 15% reduction. Services furnished in whole or in part by a physical therapist assistant or occupational therapy assistant take a 15% Medicare reduction under the CQ or CO modifier. Failing to apply the modifier results in overpayment recoupment, and failing to account for it in revenue projections overstates income.
Missing the KX modifier at the therapy threshold. The 2026 PT and SLP combined therapy threshold is $2,330 per patient. Above it, the KX modifier is required to attest that the services are medically necessary. Missing the modifier causes claim denials, and claims above the threshold may trigger targeted medical review requiring documentation.
Overestimating units per visit without documentation. The 8-Minute Rule ties units to documented timed minutes. Billing 4 units requires at least 53 minutes of timed one-on-one service. If the documentation does not support the time, the claim is deniable on audit. Project revenue based on what you can document, not what you hope to bill.
Using national Medicare rates without locality adjustment. The 2026 MPFS rates shown at GPCI 1.0 are national averages. Your locality GPCI adjusts the rate up or down. Manhattan runs about 11% above national, Los Angeles about 10% above, and many rural localities run below. Use your MAC locality GPCI for accurate per-unit rates.

Frequently Asked Questions

How much does Medicare pay for CPT 97110 in 2026?

The 2026 Medicare national rate for 97110 (therapeutic exercise) is about $30.10 per unit at GPCI 1.0, built from 0.87 total RVUs multiplied by the $33.4009 conversion factor. Locality GPCIs adjust this up or down. Manhattan pays about $32.43, Los Angeles about $32.07, and Miami about $30.13. Commercial payers reimburse $40 to $65 per unit for 97110.

What is the 8-Minute Rule for PT billing?

The CMS 8-Minute Rule governs how many units of timed CPT codes you can bill from a single therapy session. At least 8 minutes of a timed service supports one unit. Total billable units follow total timed minutes: 8 to 22 minutes is 1 unit, 23 to 37 is 2, 38 to 52 is 3, and 53 to 67 is 4. Many commercial payers use the AMA Rule of Eights instead, counting each service separately.

What is the 2026 Medicare therapy threshold?

The 2026 PT and SLP combined therapy threshold is $2,330 per patient. Above this amount, the KX modifier is required to attest that the services are medically necessary, and claims may trigger targeted medical review. The threshold is not a cap, but exceeding it without the KX modifier causes denials, and documentation must justify the medical necessity of services above it.

How does the PTA/OTA modifier affect payment?

Services furnished in whole or in part by a physical therapist assistant (PTA) or occupational therapy assistant (OTA) receive a 15% Medicare payment reduction under the CQ or CO modifier, per the CMS 2022 fee schedule final rule. A practice that uses PTAs extensively should account for this reduction in revenue projections, as it directly lowers per-unit revenue for those visits.

How do commercial payer rates compare to Medicare for PT?

Commercial payers typically reimburse 1.5x to 2x the Medicare rate for PT services. For 97110, that is about $40 to $65 per unit versus the Medicare $30.10. Workers compensation often pays $45 to $80 per unit. Practices should track reimbursement by payer to identify contracts where rates fall below the cost of delivery and negotiate improvements.

Accuracy and Disclaimer

This calculator applies the 2026 Medicare Physician Fee Schedule rates at GPCI 1.0 and commercial benchmark multipliers. Actual Medicare rates vary by locality GPCI, and commercial rates vary by payer contract and region. The 8-Minute Rule and therapy threshold figures reflect 2026 CMS rules. The AMA Rule of Eights used by some commercial payers can yield different unit counts for the same session. This is not billing, coding, or legal advice. Verify current rates and rules with your MAC and payer contracts, and consult a certified medical coder or compliance officer for guidance on your specific practice.

Conclusion

PT revenue scales with units per visit and visits per week, but the 8-Minute Rule and the therapy threshold cap both. Run the projection here, then track units per visit against the minute thresholds to avoid denials, and monitor per-patient annual charges against the $2,330 threshold to apply the KX modifier on time. Pair this with our Healthcare Revenue Cycle KPI Dashboard Calculator to benchmark the denial rate and net collection rate that determine whether projected revenue actually collects.

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