Three Medicare items a cash OT visit never meets
Bill an OT visit to Medicare and three requirements arrive together. Every line carries the GO modifier marking it as occupational therapy, with CO alongside when an OT assistant furnished the service. Once a patient’s OT spend for the year passes the KX threshold ($2,480 for 2026, tracked separately from the combined PT and speech threshold) lines without the KX modifier are denied. And the plan of care has to be certified by a physician or other qualified practitioner, then recertified at least every 90 days.
MegAligna handles none of those three automatically, and an OT practice billing Medicare in volume should know that before the demo. Modifiers are added only where a payer’s settings say so (credential tier and telehealth), so GO and KX are your biller’s to add, and certification dates are not tracked against the 90-day clock.
What the charge line carries when it leaves
What the product does handle is the line itself, built from the visit rather than typed next to it. The code booked for the visit, the delivered minutes, the place of service (clinic, home, school or telehealth) the diagnosis pointer and the rendering provider’s NPI all come from the same record the therapist documented.
Units are the delivered minutes divided by that payer’s unit length, rounded the way the payer is set up: down to whole units by default, or to the nearest unit. Each visit carries one code, so a session split between therapeutic activity and neuromuscular re-education is two lines your biller allocates. The payer settings screen previews the units any number of minutes will produce before you save, and the units calculator shows the Medicare and rule-of-eights answers for a mixed visit.
Families who pay at the visit
A large share of paediatric and hand-therapy OT is out of network: the family pays at the visit and claims afterwards. For them the practice side is a balance, a card payment and a statement, all of which work today. The superbill they send to their plan is built from the same visit data as your biller’s export, so the two cannot disagree, but the printable document waits on the AMA CPT licence we have not yet signed.
Where the units land on a claim form is Box 24G, and what a family’s superbill has to show is set out in the superbill template.
Common questions
Does OT have its own Medicare threshold, separate from PT?
Will it add the GO modifier for us?
Can a school or home session be billed from the same caseload?
Does our biller pay for a seat?
Watch minutes become OT units on a test payer
Set a test payer's unit length and rounding, close a visit for a made-up child, and read the export line it produces. Real children's records stay out until a business associate agreement is in place.