Unpacking the 2026 Final Rule FAQ

The final rule poses no shortage of questions — most of which we try to answer during our annual webinar with our own Dr. Heidi Jannenga and Gawenda Seminars President Rick Gawenda. We never get to them all, so we’ve gathered the rest here and answered them here, with expert assistance from Mr. Gawenda himself as noted.   

I thought WHO did ICD-10 codes, and AMA did CPT codes?

While the World Health Organization does set the base ICD-10 code set, in the U.S., the Center for Medicare and Medicaid Services and the Centers for Disease Control and Prevention's (CDC) National Center for Health Statistics (NCHS). 

Are we allowed to use R codes as the primary diagnosis? I thought that insurance companies were not covering those anymore.

According to Gawenda, “Yes, you are allowed to use the R codes as the primary diagnosis, and many insurers, including the Medicare program, accept R codes as a primary diagnosis.”

Were there any major changes to neck codes in October?  I have one specific patient for whom I'm suddenly getting denials. 

Gawenda suggests referencing the 2026 ICD-10 codes at https://www.cms.gov/medicare/coding-billing/icd-10-codes.

Where can we find the geographic cost price index?

CMS puts out the GCPI on its website; you can find the 2026 version here, under the Downloads section.  

Do you use an ABN if KX is used and there’s no true therapy cap?

As we outline in this blog, you would use an ABN beyond the cap if the services provided are not medically necessary. If you’re affixing the KX modifier to a claim, you’re attesting that the services are in fact medically necessary.  

How are practices handling the separate co-pays often applied to RTM codes? Are they notifying patients in advance that there may be a charge? Is this turning patients off to the service?

On this question, Gawenda states, “Yes, if known, practices are notifying patients regarding their financial responsibility. If unable to determine, I would recommend you notify patients that they may have cost-sharing associated with RTM, but we are unable to determnie the amount from the insurance carrier.”

Do they pay for CORF services as telemedicine?

“At this time, outpatient therapy can be delivered via telehealth in all outpatient settings, including a CORF, through January 30, 2026,” says Gawenda.

Does RTM require an electronic device that tracks data?  Or in the case of pediatric therapy, if we have a manual paper tracking for parents can we still bill for this?  

RTM does, in fact, require an approved electronic device or app for the purposes of tracking.  

Does RTM require prior auth for Medicaid-pediatrics?

Gawenda notes that any such requirements would be plan-specific, and you would need to check.

What if the referring provider, such as a surgeon, has the patient using an app for exercises and communication, and possibly billing RTM codes?

According to Gawenda, “If the physician and therapy practice are different entities with different TINs, and both are billing RTM, we are not seeing any issues thus far with the Medicare program.”

Can you clarify the difference between telehealth services and RTM for musculoskeletal conditions or neuromuscular conditions?

The simplest answer is that RTM involves a remote monitoring device and asynchronous monitoring through digital apps, whereas telehealth is a scheduled appointment, and services are performed in real time with a patient.   

Is RTM billed out as a separate charge from a daily visit? Could I bill that on a Friday once 20 minutes hit on its own, and have it not count as a visit if I saw them on Tuesday?

“RTM is not considered a visit. RTM codes can be billed on the same date as an in-person therapy visit for original Medicare beneficiaries,” says Gawenda.

After a patient has finished their episode of care in the clinic, how long can you continue to bill the RTM codes?

Gawenda notes, “There is no limit, but keep in mind, the patient must be under an active plan of care and still require the unique skills of a therapist to monitor and update the RTM program.”

Does analyzing a prerecorded video count in RTM as interactive communication?

No, that would not fall under the scope of RTM. RTM covers the monitoring of non-physiologic data. 

How can we find out the RVUs and GPCIs for our state?

CMS has the RVU files available for download here, and the GCPIs here. 

Is there a way to take patients with Medicare on a self-pay basis for OT?

You cannot treat Medicare patients on a cash-pay basis for services that are covered by Medicare.  

Do you know if Medicare has raised the sequestration rate for 2026?

Gawenda informs that the sequestration rate for 2026 will remain unchanged.

What were the two Medigap plans that cover the annual Medicare Part B deductible?

“Those are Medigap plans C and F. Here is a good resource to compare Medigap plans: https://www.medicare.gov/health-drug-plans/medigap/basics/compare-plan-benefits,” says Gawenda. 

We have tried to bill above the Medicare cap for PT, but at times, even after adding the KX modifier, our claim still gets rejected, and we never get paid. Do you know why?

This would warrant a conversation with your Medicare Administrative Contractor

Are we still restricted in Outpatient Part B traditional Medicare to having to see the patients 1:1? If we overlap treatments, we are supposed to bill as concurrent, correct? What is defined by 1:1? Can a tech get someone started while a therapist is working with someone else?

Gawenda states, “For outpatient therapy, therapy is either direct one-on-one patient contact or group therapy. Concurrent therapy only exists in the SNF Part A setting and not in outpatient therapy. The Medicare program does not reimburse for services provided by a rehab tech/rehab aide, even when supervised by a therapist.”

Is “higher than peers” a determined percentage of use (like if I use the 97530 code 50% of the time when I bill)?

“That percentage is not released by the CMS entities. With some medical reviews, the letter does state the practice's billing of a particular code compared to their peers' average,” says Gawenda.

How do you do MIPS? 

A very broad question! For our purposes, we’ll assume you mean how to get started with MIPS, which you can begin by checking your eligibility on the QPP website, along with your participation options and the reporting requirements to see if your practice would be interested in participating.   

So is MIPS completely optional?

If you surpass the MIPS low-volume threshold, which means you bill for more than $90,000 for Part B covered professional services, see more than 200 Part B patients, and provide more than 200 covered professional services to Part B patients, you’re likely required to participate in MIPS, unless you are part of a separate Alternative Payment Model (APM).   

For MIPS reporting, what if your primary PT in a small rural practice is not exceeding thresholds? The PT works part-time.

“If they do not exceed all 3 low-volume thresholds during both determination periods, then they are not required to participate in MIPS,” says Gawenda.