2026 Advocacy Playbook for PT and OT Professionals

How Occupational and Physical Therapy Can Transform Their Role in Healthcare

This 2026 therapy advocacy playbook is long because the problem is layered. Read it as a practical toolkit—not a test. It is written for clinicians and practice leaders who want clear, usable steps to embed physical and occupational therapy in primary care and to win Medicare and other payment reforms that reflect the value you already deliver.

You do not need policy expertise to use it; you need clinical experience, a willingness to collect simple evidence, and a few focused actions.

What you will find here:

• Plain explanations of who can change Medicare rules and why that distinction matters.
• A prioritized set of opportunities for payment and delivery change.
• Concrete evidence templates you can collect in your clinic today.
• Practical advocacy steps—what to say, where to send it, and how to build physician and ACO partners.

Why this is a good time to engage:

• Policymakers are focused on strengthening primary care and preventing high‑cost downstream care.
• Musculoskeletal and functional health are rising policy priorities with real momentum.
• CMS has recently used rulemaking to create prevention and behavioral‑health precedents that lower the bar for similar therapy asks.
• Acting now means shaping how those precedents are applied to PT and OT rather than reacting after decisions are made.

How we organize the opportunities: Levers  

Each lever in this playbook describes a single policy ask written in plain, clinician‑friendly language so you can quickly understand what’s being requested, why it matters to patients and practice, and how it could change care delivery.

Think of each lever as a short policy brief you can keep and reuse. It translates technical rulemaking or legislative concepts into the practical terms clinicians use, such as what the change would look like for practicing clinicians, what simple evidence would support it, and how to spot it in future policy conversations. These are durable, action‑oriented summaries designed so you can recognize opportunities and begin to contribute in the ways you feel most aligned with.

Below is the Table of Contents to guide your reading. Start with the short front sections to get the big picture, then skim the Levers to get an idea of what this is proposing.

Table of Contents

1. The History of Undervaluing Therapy: A Call to Action
2. The Landscape Right Now: Why This Moment Is Different
3. We Are the Missing Leg: Making the Primary Care Case
   • The Three-Legged Stool
   • We Have to Change Our Own Narrative
4. Our Why: The Aging-in-Place Crisis
5. Centers for Medicare and Medicaid Services (CMS) vs. Congress: Who Can Change What and How
   • The Statutory Basis: Where CMS’s Authority Comes From
   • The HCPAC: Therapy’s Formal Seat at the Table
   • What CMS Can Do Through Rulemaking
   • An Important Correction on the MPPR
   • What Congress Controls
   • The Authority Map at a Glance
6. The Menu of Levers: What CMS Can Do, and What We Can Ask For
   • Lever 1: Prevention-Focused Functional Assessment G-Codes
   • Lever 2: Tiered Work RVUs for Evaluation Complexity
   • Lever 3: Practice Expense RVU Modernization
   • Lever 4: Efficiency Adjustment Redistribution
   • Lever 5: Therapy-Specific Longitudinal Complexity Add-On Code
   • Lever 6: Interprofessional Consultation G-Codes
   • Lever 7: Care Coordination, RTM, and Telehealth
   • Lever 8: MPPR Reform Through Rulemaking
   • Lever 9: Rural Health Clinics and FQHCs
7. Getting Into the Room: A Strategy for Real Influence
   • Win Primary Care as Champions
   • Publish Where Policymakers Read
   • Engage the VBC and ACO Community
   • Engage the CMS Formal Process — Every Year
8. Practice Owners: The Leadership Is on You
9. A Realistic Timeline: What Progress Actually Looks Like
   • Now to 3 Months: Build Fluency and Internal Infrastructure
   • 3 to 12 Months: Produce Proof and Build Relationships
   • 12 to 36 Months: Translate Proof Into Policy Momentum
10. CMMI: The Lever We Cannot Afford to Ignore — And What’s Coming in Blog 3

The History of Undervaluing Therapy: A Call to Action

In the first blog of this series, The Therapy Reimbursement Guide, we traced the full history of how physical and occupational therapists ended up where we are: underpaid relative to our clinical contribution, structurally disconnected from primary care, and financially squeezed by a fee-for-service system that was never designed to capture the value we create.

We also walked through how the Medicare Physician Fee Schedule works, why relative value units were created, how budget neutrality operates as an invisible ceiling, and what the Multiple Procedure Payment Reduction has done to practice economics over more than a decade. If any of that is unfamiliar territory, go read Blog 1 first. Everything we are about to say assumes that foundation.

This blog is about what comes next.

Understanding the history is necessary. But understanding the history without a strategy leaves therapists feeling informed and stuck. We have all sat in rooms where someone explained brilliantly how broken the system is and then left without any meaningful idea of what to do about it. This blog is not that experience.

This blog is a working policy playbook: concrete, specific, grounded, and strategically sequenced. We are going to name the decision-makers and regulatory channels that can actually change things, explain which levers are within CMS’s existing authority and which require Congress, and give you a realistic picture of what engagement in this system actually looks like. We are also going to give you something the profession has needed and largely lacked: a clear-eyed account of which arguments will move the system and which ones will not.

Here is the mindset shift we need first: the problem is not that the system is broken beyond repair. The problem is that we have not yet positioned ourselves, organized ourselves, or engaged the process strategically enough to be seen as part of the solution. That is a problem we can solve. And right now, in this specific political and policy moment, we have an opening we have not had before.

The window will not stay open forever. Let’s use it.

The Landscape Right Now: Why This Moment Is Different

Every generation of therapists has believed that the next fee schedule cycle might finally be the one. It has not been.

If we are honest, it will not be, as long as our primary strategy is hoping for a better conversion factor. Combined OT and PT reimbursement rates are down roughly 40 percent since 2002 in inflation-adjusted terms. Large national therapy chains that bet everything on squeezing profitability out of higher fee-for-service volume have, many of them, collapsed. The writing is on the wall.

But something meaningful is different right now, on two fronts that converge directly on where we stand.

The first is a bipartisan, sustained policy consensus that primary care has been undervalued and underfunded for decades, with wide recognition that money spent in primary care creates exponential downstream savings. Policymakers across the political spectrum agree that the healthcare system cannot sustain itself if it keeps paying for downstream, high-cost interventions while chronically underfunding the upstream prevention, chronic disease management, and care coordination work that keeps people healthy and out of hospitals.

This is not a new idea. What is new is that it is being acted on with urgency and real resources.

The second is that musculoskeletal conditions are beginning to receive the quality of policy attention similar to what behavioral health received in the years following COVID-19. Think about what happened to behavioral health: a national conversation about mental health, a sustained clinical and economic argument from behavioral health providers and their physician champions, and a concrete response from CMS. This includes new codes, higher RVU weights, access to interprofessional consultation codes, and integration into CMMI models.

Behavioral health providers, their champions, supported by public demand, made the case fluently, in the right rooms, to the right people, over a sustained period. No lobbying miracle. No single legislative win. A strategic, multi-year engagement that paid off.

Musculoskeletal conditions are beginning to get that attention now, and PTs and OTs need to acknowledge it and capitalize on it. There is a combination of rising surgical costs, opioid dependence concerns, and the crushing access burden on primary care physicians that has made musculoskeletal care a genuine policy priority.

CMS Administrator Dr. Mehmet Oz has explicitly named a shift from sick care to prevention and wellness as a central priority. The CMMI director has emphasized evidence-based prevention and patient empowerment. The Administration’s interest in reducing healthcare costs while expanding access creates a political frame that maps almost perfectly to what we offer.

This is our behavioral health moment. We cannot look back in five years and realize we missed it.

The question is not whether we can change the future of PT and OT. The question is whether we are willing to learn the playbook, engage the process, and lead with the evidence and the allies we need to be taken seriously.

We Are the Missing Leg: Making the Primary Care Case

The core argument we must learn to make fluently, consistently, to every stakeholder audience is not about reimbursement. It is about positioning. And the positioning argument is this:

Primary care cannot achieve its goals without therapists embedded in it, and the evidence to prove that is already in our hands.

Think about what advanced primary care teams have demonstrated when they actually have the resources to function. Studies of comprehensive primary care practices, including those operating within accountable care organizations and patient-centered medical homes, have consistently shown that teams with integrated care coordination, behavioral health, and population health management staff reduce emergency department visits, hospitalizations, and per-beneficiary Medicare spending.

Research on early physical therapy for low back pain has found significantly lower rates of downstream imaging, injection therapy, and surgery compared to traditional medical pathways. Falls prevention programs led by PTs have demonstrated sustained reductions in fall rates and associated hospitalizations, with returns on investment that exceed intervention costs by multiples.

Occupational therapy carries equally compelling evidence. Studies of OT-led home modification and activity-based intervention programs for community-dwelling older adults have found significant reductions in functional decline, falls, and caregiver burden. The landmark Well Elderly studies demonstrated that preventive occupational therapy — focused on meaningful daily activities, home safety, and adaptive strategies — produced measurable improvements in health, function, and quality of life compared to control groups, with effects that persisted at follow-up. For a Medicare population whose primary policy risk is institutionalization, that kind of upstream functional intervention is precisely what the system should be paying for and is not.

Notice what is almost always missing from those advanced primary care teams: a physical therapist or occupational therapist. Behavioral health integration is now common in sophisticated primary care models. Pharmacy integration is growing. Therapy is the notable, systematic absence — and that absence has a cost the system is bearing without clearly seeing it.

The Primary Care Triad: The Needed Three-Legged Stool

The frame we should use consistently with every policymaker, physician, ACO leader, and patient-advocacy organization is straightforward: primary care needs three legs to stand on. The first is medical: diagnosis, medication management, disease monitoring. The second is behavioral: mental health, substance use, behavior change support. The third — the leg that is missing — is functional and rehabilitative: movement, musculoskeletal health, fall prevention, home safety, ADL performance, cognitive-functional integration, and the practical work of staying independent as we age.

Behavioral health made this argument successfully, and CMS responded over time with new codes, higher RVU weights, access to interprofessional consultation billing, and integration into CMMI models. We need to make the functional health argument with the same clarity, the same evidence base, and the same coalition of physician champions behind it.

The aging of the Baby Boom generation has made functional health a genuine national policy priority. Keeping people out of nursing facilities and in their homes is simultaneously the preference of the people and a fiscal necessity for Medicare and Medicaid. The Administration knows this. We are the providers who make aging in place possible at scale. We should be saying that loudly and consistently.

We Have to Change Our Own Narrative

We have to acknowledge something honestly: our profession helped create the narrative problem we are trying to fix. The hard-won victories of direct access and independent practice authority (which were genuine wins) carried an unintended message: that therapists are specialists who practice independently of primary care. That narrative has made it harder to position ourselves as primary care team members. Pair that with a fee-for-service incentive structure that rewarded high-frequency, high-volume care models, and the result is a perception among some physicians and payers that therapy is a high-commitment, unpredictable-total-cost specialty service rather than a scalable, preventive, upstream, primary care resource.

The path to changing our payment runs through changing that narrative. The path to changing that narrative runs through embedding ourselves in primary care delivery, building the evidence base there, and earning the physician champion relationships that give our advocacy real credibility in the rooms where decisions are made.

Our Why: The Aging-in-Place Crisis

The Primary Care Triad isn’t just a clinical ideal; it is the only viable response to a massive fiscal and demographic pressure point: the Aging-in-Place Crisis.

While the medical and behavioral legs of the stool handle parts of disease management and mental health, the Rehab Therapy leg is the only one equipped to mitigate the specific functional risks that currently bridge the gap between home and institutionalization.

Physical and occupational therapists are trained and positioned to address the functional risks that drive institutionalization. They include but are not limited to:

• impaired lower extremity power
• upper extremity impairments
• impaired fine motor coordination
• balance deficits 
• fall risk
• unsafe home environments
• declining ADL performance
• caregiver exhaustion 

A skilled nursing facility admission under Medicare for post-acute care costs around $400-$900 dollars per day depending on location, payer, and patient complexity. 

Long-term care under Medicaid costs tens of thousands of dollars per year per beneficiary. 

Functional risk reduction that avoids even a fraction of those admissions? That generates returns that dwarf the cost of the preventive services involved.

MedPAC, the independent congressional advisory body that advises Congress on Medicare payment policy, has actively recommended that Congress direct CMS to improve the accuracy of relative values by collecting and using timely data that reflect the current cost of delivering care. When therapy advocates press for PE modernization, they are asking CMS to do what MedPAC is already telling Congress to require. That alignment should be cited explicitly in advocacy materials.

CMS has begun to recognize the aging-in-place imperative operationally. The GUIDE model for dementia care includes therapists and caregiver training for the first time in a CMMI model. 

Caregiver training codes were added to the fee schedule in connection with dementia care. 

The TEAM model creates bundled payment structures that incentivize efficient, high-quality post-surgical episodes of recovery. 

These are early signals, and they point in exactly the direction we need to accelerate.

The argument to policymakers and primary care partners is this:

• You are trying to help an aging population maintain independence. 
• You do not have the primary care workforce to do it alone. 
• Behavioral health integration has helped with the mental and behavioral dimensions. 
• But there is a whole dimension of functional health that includes things like mobility, fall prevention, home safety, strength, daily function, and so much more that behavioral health obviously does not address. 

The good news? PTs and OTs address it. 

We have the workforce, the training, and the evidence. We need to be structurally embedded in the care models you are building.

The fiscal urgency of the aging-in-place crisis gives us the ‘why,’ and the Primary Care Triad gives us the ‘what.’ However, turning these clinical proof points into actual payment requires a mastery of the ‘how.’ Before we can pull the individual levers of change, we must map the territory of the decision-makers—CMS and Congress—who hold the power to turn these functional interventions into a standard Medicare benefit.

CMS vs. Congress: Know Who Can Do What

One of the most persistent and costly mistakes therapists make in policy engagement is conflating CMS with Congress. They are not the same. They operate on different timelines, under different rules, and with different legal authority. Aim your advocacy at the wrong target and you waste resources, miss windows, and exhaust the goodwill of the people you are trying to persuade. Knowing the statutory architecture of Medicare is the foundation upon which to craft a sound plan.

The Statutory Basis: Where CMS’s Authority Comes From

CMS administers Medicare under authority delegated by Congress through the Social Security Act. The Physician Fee Schedule — the payment system that covers most PT and OT outpatient services — was created by Section 1848 of the Social Security Act, enacted through the Omnibus Budget Reconciliation Act of 1989. Section 1848 gives the Secretary of Health and Human Services — acting through CMS — substantial rulemaking authority over how physicians and nonphysician practitioners are paid under Medicare Part B.

Within that authority, CMS sets and adjusts relative value units through the annual Physician Fee Schedule rulemaking process, drawing on recommendations from the AMA/Specialty Society Relative Value Scale Update Committee, or RUC, as well as MedPAC, public commenters, published research and other content, and its own analysis. Critically, CMS is not bound to accept RUC recommendations — it accepts the great majority of them, but it has authority to deviate when it concludes that recommended values do not accurately reflect the resources involved in furnishing a service.

The practice expense component of each code — which is the dominant RVU component for most PT and OT codes — is governed by a specific statutory requirement in Section 1848(c)(2)(C)(ii) of the Social Security Act: CMS must use a resource-based system for determining practice expense RVUs, reflecting actual direct and indirect expenses of delivering care. This is a meaningful legal hook for the PE modernization argument.

If CMS is using outdated cost data while more accurate data exists and has been submitted, it is arguably not fully implementing the statutory standard. In fact, when APTA reported that CMS “set aside” favorable practice expense survey data for PT in the 2026 final rule, that is both a disappointment and a potential regulatory challenge worth pressing.

The HCPAC: Therapy’s Formal Seat at the Table

Physical and occupational therapists have a formal channel into the RVU process that many practitioners do not know exists: the Health Care Professionals Advisory Committee, or HCPAC. The HCPAC was formed in 1992 alongside the RUC to allow non-physician health care professionals to participate in the relative value recommendation process. Both APTA and AOTA hold seats on the HCPAC, alongside audiologists, chiropractors, clinical social workers, physician assistants, psychologists, and others.

HCPAC members, together with three physician members of the RUC, form the RUC HCPAC Review Board, which is responsible for developing RVU recommendations for new, revised, and potentially misvalued codes that CMS then considers in the annual rulemaking process. This is the formal mechanism for code revaluation requests — and it requires organized, data-driven submissions. Time-motion studies, practice cost surveys, and comparative analysis against analogous physician codes are the currency of the HCPAC process.

The HCPAC is a real lever. The question is whether our associations are using it as aggressively as the evidence supports, and whether practice owners are generating the outcome data and cost data those submissions require.

What CMS Can Do Through Rulemaking

Within its Section 1848 authority and the broader HCPCS coding authority, CMS can do a great deal through the annual proposed rule and final rule process — entirely without congressional action:

• Create new billing codes — HCPCS G-codes — for services that do not yet have a payment pathway, and expand access to existing codes to new provider types where the statutory definition permits
• Revalue existing codes by adjusting work RVUs, practice expense RVUs, and malpractice RVUs
• Conduct efficiency adjustments that redistribute value within the fixed PFS budget, guided by its own analysis of service resource use
• Designate codes as “potentially misvalued” and initiate systematic review under Section 1848(c)(2)(K) of the Social Security Act
• Design and launch CMMI payment models that test new delivery and payment approaches, with authority to operate outside PFS budget neutrality constraints
• Set coverage criteria, supervision requirements, and documentation standards through rulemaking

One important structural reality shapes nearly every CMS ask for therapists: physical and occupational therapists cannot bill Evaluation and Management codes. E/M codes — the 99202 through 99215 family — are available to physicians and a defined set of non-physician practitioners including nurse practitioners, physician assistants, and clinical nurse specialists. PTs and OTs are not on that list, and that is not a CMS rulemaking question — it reflects the statutory definitions of covered services in Sections 1861(p) and 1861(g) and how CMS has long interpreted billing authority under Part B.

This matters because several codes that might seem directly applicable to therapists — including G2211, the longitudinal care complexity add-on — are structurally inaccessible to us. G2211 must be reported alongside an E/M code on the same day of service. Because therapists cannot bill E/M codes, they have no base code to attach G2211 to, regardless of whether their clinical work fits the description.

This is not a dead end. It’s actually a map. The solution is to ask CMS to create parallel G-codes for therapists that accomplish the same policy purpose. This is precisely what CMS did for behavioral health providers in 2025: clinical psychologists and social workers also cannot bill E/M codes, so rather than extending existing CPT interprofessional consultation codes, CMS created new G-codes (G0546–G0551) that mirror those codes in function and attach to behavioral health service codes instead. That model — new G-code, same policy purpose, different base code — is the correct template for every equivalent ask we make.

CMS also sets the standard that commercial insurers and Medicaid programs frequently follow. Changes to Medicare payment policy ripple across the broader payment landscape in ways that make CMS advocacy disproportionately high leverage.

An Important Correction on the MPPR

It’s common to see the Multiple Procedure Payment Reduction issue framed as a congressional mandate that only Congress can fix. This is not entirely accurate, and the distinction matters for our strategy.

Section 3134 of the Affordable Care Act added Section 1848(c)(2)(K) to the Social Security Act, which directed the Secretary to identify potentially misvalued codes by examining multiple codes that are frequently billed together for a single service. In response to that statutory directive, CMS implemented the MPPR on therapy services through rulemaking, applying a 50 percent reduction to the practice expense component of the second and subsequent timed therapy procedures in a single session.

Congress directed CMS to find misvalued bundled codes; CMS chose to apply that authority to therapy and set the specific reduction rate.

That is a critical distinction. CMS implemented the therapy MPPR through rulemaking not because Congress mandated the specific 50 percent therapy reduction. CMS likely has regulatory authority to reduce or eliminate the MPPR on therapy through the same rulemaking process, if presented with compelling evidence that the policy creates misaligned incentives and does not reflect actual therapy service economics. Congressional action would be a backup if CMS declines, but the CMS regulatory route should be pursued first.

Why the MPPR Argument to CMS Is Winnable: The MPPR originated in 1995 applied to nuclear medicine procedures, was extended to diagnostic imaging services in 2006, and was extended to therapy in 2011 — on the theory that when multiple services are furnished together, certain practice expense activities like patient preparation and equipment setup occur only once. That theory holds for imaging, where a technician sets up equipment once for multiple scans. It does not hold for therapy: there is no meaningful shared setup between a unit of therapeutic exercise and a unit of neuromuscular reeducation. The clinician is the setup, and that engagement does not diminish with the second procedure. Presenting time-motion data demonstrating this — alongside evidence that the MPPR creates perverse incentives toward fragmented care and higher visit counts — is a credible regulatory argument. Interventional pain specialists won a partial RVU restoration in 2025 using exactly this type of organized data submission.

What Congress Controls

Congress writes Medicare statute and controls federal spending. Congressional action is required when changes need new statutory authority. This includes:

• Creating a new Medicare benefit category
• Revising the definitions of covered therapy services in Sections 1861(p) and 1861(g)
• Eliminating physician plan of care requirements
• Expanding which provider types can bill independently for specified services
• Appropriating money outside PFS budget neutrality for telehealth or pilot programs
• Legislating specific payment floors or protections

When Congress acts, it is not bound by PFS budget neutrality. That is a genuine advantage. But the legislative pathway is slower, more competitive, more expensive to pursue, and more subject to political cycles and the federal deficit environment.

Consider how difficult it has been to make telehealth permanent. It’s a change with overwhelming bipartisan support, strong evidence, and no real opposition. The problem is largely because Congressional Budget Office (CBO) scoring requirements create obstacles.

The Physical Therapist Workforce and Patient Access Act, introduced in the 118th Congress, would have allowed PT services to be billed at cost-based Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) rates rather than the PFS, bypassing budget neutrality entirely for those settings. It failed to pass and did not include occupational therapy — a gap that must be corrected in any future legislative effort. But it illustrates a viable and important legislative model that both professions should pursue together.

Congressional engagement matters and should absolutely continue. But it should be the long game, backed by evidence and champions built through CMS engagement, not the first resort.

The Authority Map at a Glance

The table below summarizes each major policy lever, who has authority to implement it, and the practical route to pursue it. This should serve as a reference for practice owners and association leaders planning advocacy engagement:

Policy Lever	Who Has Authority	Route to Change
Lever 1: G-code creation (functional assessment)	CMS regulatory authority	PFS proposed rule comment period
Lever 2: Work RVU differentiation (eval complexity)	CMS via HCPAC/RUC process	HCPAC submission + PFS comment letter
Lever 3: PE RVU modernization	CMS regulatory (SSA §1848(c)(2)(C))	Specialty cost survey + PFS comment letter
Lever 4: Efficiency adjustment inclusion	CMS regulatory	Pre-rule letter (Feb–Apr) + PFS comment
Lever 5: Therapy complexity add-on (G2211 parallel)	CMS regulatory — new G-code via HCPCS authority	PFS comment citing G2211 + BH G-code precedents
Lever 6: Interprofessional consultation G-codes	CMS regulatory	Behavioral health 2025 G-codes as direct precedent
Lever 7: Care coordination, RTM, and Telehealth (Lever 7)	CMS regulatory (care coord + RTM); Congressional action required (telehealth permanence)	PFS comment + HCPAC submission; CONNECT for Health Act for permanence
Lever 8: MPPR reform or elimination	CMS regulatory (implemented by rule); 50% rate has congressional footprint	PFS comment with data; congressional backstop
Lever 9: Rural Health Clinic / FQHC inclusion	Congressional statutory action required	Active legislative ask; IOP OT precedent strengthens case

The Menu of Levers: What CMS Can Do, and What We Can Ask For

What follows is not a wish list. Each lever is grounded in CMS’s existing statutory authority, in precedents CMS has already established, and in the specific priorities the current Administration has articulated. The argument for each should lead with how it serves CMS’s goals and not with how much therapists need the money.

Remember, budget neutrality means every dollar we gain must come from somewhere. The system moves when we demonstrate that our services produce savings that justify the shift.

Lever 1: Prevention-Focused Functional Assessment G-Codes

Why This Is Our Lead Ask

This may be the highest-feasibility near-term ask we can make, and we should lead with it.

CMS has recently created multiple prevention-focused G-codes entirely through rulemaking with no congressional action required. G0136, finalized in the 2026 PFS final rule, provides payment for a standardized, evidence-based assessment of nutrition and physical activity. It is valued on practice expenses and professional liability only. It supports CMS’s prevention priorities. It was created because CMS has clear authority to pay for standardized preventive assessments when clinical evidence shows they produce measurable downstream benefit and downstream cost reduction.

CPT codes 96160 and 96161, which are health risk assessment instruments, provide further precedent. These codes cover administration and scoring of standardized patient-completed health risk instruments, are valued on practice expense and professional liability only, can be performed by clinical staff, and serve a preventive function. They are billed adjacent to physician visits and have no mandatory face-to-face requirement beyond what the instrument itself requires.

This is the direct model for a functional assessment G-code.

What We Are Proposing

PTs and OTs are the providers most qualified to administer and interpret standardized functional assessments: the Timed Up and Go, the Berg Balance Scale, the STEADI falls risk battery, the Lower Extremity Functional Scale, PROMIS measures, the DASH, the 6-Minute Walk Test.

We do (or should be doing) this work now, but there is no separate payment code for it. It is bundled into evaluation codes, making it invisible and unrecognized as a distinct preventive service.

The proposal: a new G-code or G-code family for standardized functional outcome assessment by a PT or OT. It will cover falls risk screening, mobility assessment, and functional limitation measures, and be valued on practice expense and professional liability. It will be billable once or twice annually as a preventive service, with a strong argument for cost-sharing waivers as a true preventive benefit.

Framing: this is CPT 96160/96161 for functional health, parallel to G0136 for nutrition and physical activity.

The Evidence and the Physician Champion Strategy

The evidence package is strong. Falls prevention programs generate documented returns of multiple dollars for every dollar invested. Early functional assessment identifies the patients at highest risk of costly downstream events. The standardized tools, documented scoring procedures, and EHR integration already exist in most therapy practices. This is not a new service. It is a new payment pathway for a service we are already providing without recognition.

Critical success factor: primary care physician organization letters of support framing this as a complement to the Annual Wellness Visit — a service that extends the physician’s capacity to address functional drivers of health that they do not have time or training to assess themselves. The pitch to physicians is equally important: this code supports longitudinal care partnerships and helps ensure patients stay within the primary care ecosystem rather than seeking care elsewhere.

Lever 2: Tiered Work RVUs for Evaluation Complexity

The Problem

In 2017, CMS adopted three complexity levels for PT and OT evaluations: low, moderate, and high. The codes acknowledge that evaluating a patient with simple, acute musculoskeletal complaints involves meaningfully different clinical work than evaluating a patient with multiple comorbidities, cognitive impairment, complex functional deficits, and a complicated social situation. History-taking, examination breadth, clinical decision-making time, and documentation burden are all substantially different across these levels.

Despite this, all three levels carry identical work RVUs of approximately 1.54. CMS already recognizes exactly these distinctions in physician Evaluation and Management codes — that is the entire premise of the 99202 through 99215 coding system, where work RVUs scale with complexity. The precedent is explicit. The three-tiered structure already exists in our codes. What is missing is differentiated payment that actually reflects what the complexity levels were created to capture.

The Ask

Differentiate work RVUs across the three evaluation complexity levels through HCPAC submission to the RUC, supported by time-motion study data, clinical decision-making documentation, and direct comparison to analogous physician E/M code values. This is a HCPAC process engagement combined with a direct CMS comment argument. The clinical case is straightforward and the precedent is explicit.

Lever 3: Practice Expense RVU Modernization

Why PE Matters More for Therapy Than for Most Providers

Every Medicare payment to a therapist includes a practice expense component intended to cover the overhead of delivering that service: staff time, space, equipment, technology, administrative costs, and supplies. Unlike physician services broadly, where work RVUs account for roughly half of total payment, PT and OT codes are paid exclusively at non-facility practice expense rates regardless of setting, a statutory rule that makes PE a particularly large and consequential component of therapy reimbursement. For timed treatment codes in particular, where the work RVU component is relatively modest, PE is the dominant driver of what Medicare actually pays.

That makes the statutory requirement in Section 1848(c)(2)(C)(ii) particularly consequential for our profession: CMS is legally required to use a resource-based system for determining PE RVUs that reflects the actual current costs of delivering care — not historical estimates carried forward from a base period that no longer reflects how therapy practices operate.

CMS Has the Data and Has Not Used It

APTA has reported that in the 2026 PFS final rule, CMS set aside practice expense survey data favorable to PTs — and the same pattern applied to occupational therapy and physician specialties, where CMS declined to incorporate updated Producer Price Index survey data submitted by multiple organizations including AOTA, APTA, and the AMA. CMS acknowledged the concerns but stated it required additional methodological development and budget-neutrality modeling before the data could be incorporated into future rulemaking. Critically, CMS explicitly invited future submissions — specifically calling for detailed survey data, time and intensity analyses, updated PE documentation, and evidence of changes in technology or workflow. That is not a rejection. That is a to-do list.

Our associations should be treating it as a specific, CMS-authored roadmap for the submission that gets PE values updated in a future rule cycle. The statutory obligation is clear, CMS has told us what evidence it needs, and the next submission should be built to answer every condition CMS named.

Radiology successfully documented that equipment costs and technology requirements had shifted substantially and won PE value updates in 2023. The pathway is established. What it requires is organized, data-driven engagement: time-motion studies, practice cost surveys across clinic types and sizes, and a formal HCPAC submission with a direct challenge to CMS’s PE inputs for high-volume therapy codes.

Lever 4: Claiming Our Place in Efficiency Adjustment Redistribution

What Happened in 2026 and Why It Matters

The 2026 PFS final rule included efficiency adjustments that shifted work RVUs toward time-based cognitive services — specifically benefiting physician E/M codes and behavioral health services. The stated rationale: certain non-time-based procedures have become more efficient to perform over time, freeing resources that should be redistributed toward services requiring sustained clinician time, judgment, and direct engagement.

For therapy, the 2026 rule was a defensive win rather than a positive gain. The Alliance for Physical Therapy Quality and Innovation (APTQI) submitted an organized comment letter in September 2025 arguing that specific therapy codes, including 97032, 97113, 97124, and 97140, had been incorrectly placed on the efficiency adjustment cut list. CMS agreed and removed them from the list, preventing payment reductions for those codes. That outcome was real and meaningful. But while therapy avoided cuts, it did not share in the redistribution that benefited primary care and behavioral health providers whose time-based codes received higher RVU weights. We held our ground. We did not advance.

The Opportunity: Acting Before the Rule Is Written

The CY 2027 proposed rule is the immediate live opportunity. The moment to act is now, not when the proposed rule is published in July. By the time CMS releases a proposed rule, the substantive decisions have largely been made internally. The organizations that shape what CMS proposes are engaging in the winter and spring through direct letters to CMS leadership: formal advocacy letters addressed to the CMS Administrator and the Director of the Center for Medicare, submitted between February and April, laying out specific asks with supporting clinical and economic data. These are not part of the formal rulemaking docket. Instead, they are direct engagement with the people writing the rule before it is written. Major physician societies, hospital systems, and behavioral health organizations submit these routinely as part of how the system actually works. Our associations should be doing the same, and practice owners who have outcome data and a clear policy argument can and should send their own.

When the proposed rule is published in July and the formal comment period opens, with comments due in mid-September, that is a critical second opportunity to build the public record. Both windows matter. The February-to-April engagement shapes what gets proposed; the September comment shapes what gets finalized.

Read our Pre-Rulemaking Comment Letter to CMS here.

The Argument: Primary Care Team Member, Not Afterthought

The argument to make in both channels — clearly, with data, and in explicit alignment with the primary care and behavioral health organizations that have already benefited from the efficiency adjustment redistribution — starts with positioning, not payment. CMS designed this framework to strengthen the primary care team and the cognitive, relationship-based services that hold it together. Physical and occupational therapists are members of that team. We are the functional leg of the primary care stool that behavioral health and medical care cannot replace — addressing the mobility, musculoskeletal, fall risk, and daily function challenges that primary care physicians do not have the time or training to manage, and that drive some of the most costly downstream utilization in Medicare. We have been structurally under-recognized as primary care contributors, and that under-recognition is reflected in a redistribution that rewarded our teammates and passed us by.

The follow-on argument is about code structure, and it is equally clean: every timed unit of therapeutic exercise, therapeutic activity, or neuromuscular reeducation requires full clinician engagement, ongoing clinical decision-making, patient education, and care coordination — exactly the profile of service the efficiency adjustment framework was built to reward. Primary care and behavioral health were its first beneficiaries. We should be next. Framing this as an extension of a framework CMS has already committed to, on behalf of a care team member CMS has not yet fully recognized, is both more accurate and more likely to move the room than treating it as a standalone therapy reimbursement ask.

Lever 5: A Therapy-Specific Longitudinal Complexity Add-On Code — The G2211 Parallel

This Is Different From Lever 2

This lever is categorically different from Lever 2, and the distinction matters for how we frame the ask. Lever 2 addresses visit-level complexity. This is the argument that a high-complexity evaluation involves materially different clinical work than a low-complexity one, and that work RVUs should reflect that difference within the evaluation code itself. That is an accuracy argument about a single encounter.

This lever addresses something different entirely: the ongoing relationship between a therapist and a patient over time. The complexity being recognized here is not what happened in today’s evaluation. It is the cognitive and relational burden of being the provider who manages a patient’s functional health longitudinally.

This includes maintaining a clinical picture across visits, adapting the plan of care as the patient’s condition evolves, coordinating with physicians and other team members, and serving as a consistent, trusted point of contact for patients managing chronic and complex conditions. A patient could have a straightforward low-complexity visit on any given day and this add-on would still apply, because what it recognizes is the relationship context and the longitudinal management responsibility, not the difficulty of that particular session.

What CMS Already Recognized in G2211

This is precisely the distinction CMS drew when it created G2211 for physicians. The E/M complexity codes already captured visit-level complexity. G2211 was created because those codes did not capture the additional work inherent in being someone’s continuing care provider. This involves the accumulated clinical knowledge, the care integration responsibility, the behavior change work that only becomes possible in a sustained relationship. 

CMS explicitly framed G2211 as recognizing a different dimension of work entirely, not a harder single visit. Physical and occupational therapists provide exactly this kind of longitudinal, relationship-based, complexity-managing care, and we have no payment mechanism that recognizes it.

A Commitment That Changes How We Are Perceived

Here is where the argument becomes genuinely compelling to policymakers, and where our profession has an opportunity to make a commitment that changes how we are perceived in the policy space. Accessing a longitudinal complexity add-on would not be a passive billing decision. It would signal that the therapist is committing to an ongoing care relationship with that patient and not an episodic course of treatment with a defined end date. It would mean the therapist has a continuing, functional health partnership of the kind that primary care physicians maintain with their panels.

That is a fundamentally different practice model than the traditional therapy episode, and it is exactly the model that makes therapists true members of the primary care team rather than specialists who treat a problem and discharge the patient. Policymakers who have spent years trying to shift healthcare toward longitudinal, relationship-based primary care understand immediately why that commitment matters. It is the difference between a consultant and a teammate. When we ask for this code, we are declaring what kind of providers we intend to be.

That commitment also creates accountability that strengthens the policy argument. If therapy practices billing a longitudinal complexity add-on are expected to maintain ongoing functional health relationships with those patients, including tracking outcomes over time, coordinating with the primary care team, and adapting care as the patient’s needs change, then the data those relationships generate becomes the evidence base for every other ask on this list.

Longitudinal functional outcome data from committed therapy-primary care partnerships also supports our asks on functional assessment G-codes, interprofessional consultation codes, and CMMI model inclusion. The longitudinal relationship is not a billing rationale. It is the proof point engine for the entire policy agenda.

We Cannot Ask for G2211 Itself. Here’s What We Should Ask for Instead

One important note: we cannot ask for G2211 itself. The G2211 code must be reported alongside an E/M code on the same day of service, and therapists cannot bill E/M codes. That is not a scope of practice limitation in the policy sense. It reflects how CMS has defined billing authority under Part B, and it is a structural barrier regardless of how compelling our clinical argument is. Asking CMS to extend G2211 access to PTs and OTs would fail on that basis before the clinical argument was even heard.

The right ask (and it is a strong one) is for CMS to create a new therapy-specific longitudinal complexity add-on code that accomplishes exactly what G2211 accomplishes for physicians, but attaches to therapy evaluation codes (97161–97163 for PT, 97165–97167 for OT) rather than E/M codes. The precedent for this structure is direct and recent. 

Behavioral health providers face the same E/M billing barrier therapists do — clinical psychologists and social workers cannot bill E/M codes — so when CMS wanted to create a parallel recognition mechanism for them, it did not extend existing CPT codes. It created new G-codes that mirror those codes in function and attach to behavioral health service codes instead. CMS has now demonstrated twice that it will build parallel G-code structures for non-physician providers who are excluded from the E/M billing architecture. That is the model and the precedent we cite.

G2211 was finalized in the CY 2021 rule, but specialist physician organizations lobbied successfully to delay its implementation, and Congress obliged through the Consolidated Appropriations Act of 2021, pushing the effective date to January 1, 2024. That history cuts both ways. It demonstrates that organized stakeholder engagement directly shapes when and how CMS policy lands — in either direction. Specialists used that leverage to delay a code that reduced their payments. We should be using it to accelerate a parallel code that recognizes ours, before the political window that currently favors primary care integration and prevention closes.

The argument to CMS: you have established the principle that longitudinal relationship complexity deserves add-on recognition, and you have demonstrated twice that you can and will create parallel G-code structures when the existing code architecture excludes a provider type with a legitimate clinical case. Physical and occupational therapists meet both conditions. We are prepared to commit to the longitudinal care relationships that justify the code. We need the G-code equivalent of G2211, and the behavioral health codes finalized in 2025 are the direct structural model.

Lever 6: Interprofessional Consultation G-Codes — Following Behavioral Health’s 2025 Lead

What CMS Built for Behavioral Health

This is one of the most direct and immediate opportunities the profession has not yet organized around, and the window to frame it as an extension of existing policy momentum is right now.

In 2025, CMS created G-codes G0546 through G0551 giving behavioral health providers a new billing pathway for interprofessional consultation services. These codes are billed by the behavioral health provider (a clinical psychologist, clinical social worker, mental health counselor, or marriage and family therapist) when a treating provider requests their expert input on a shared patient’s diagnosis or treatment. The behavioral health provider reviews the case, engages in a consultative discussion with the treating provider, and delivers a written report. They do this all without a face-to-face visit with the patient.

CMS was explicit in the final rule about why new G-codes were necessary rather than simply extending the existing CPT interprofessional consultation codes (99446–99451) that physicians use. It’s because behavioral health providers, like physical and occupational therapists, cannot independently bill Medicare for E/M visits, and E/M billing eligibility is a prerequisite for both sides of the existing CPT consultation framework. That language, “cannot independently bill Medicare for E/M visits,” is not incidental. It is the structural parallel to therapy stated directly in CMS’ own rulemaking record, and it is a citation our associations should be putting in front of CMS explicitly when making the case for therapy interprofessional consultation codes.

That structural barrier is identical to the one therapists face. It’s also precisely why CMS built a parallel G-code structure rather than expanding access to existing codes. CMS has now demonstrated twice that it will do this for non-physician provider types excluded from E/M billing. That is the precedent we cite for both the longitudinal complexity add-on and the interprofessional consultation ask.

The principle CMS has established is this: non-face-to-face coordination and consultation between providers creates clinical value and should be compensated. There is no principled reason that recognition stops at behavioral health.

The Work We Are Already Doing Without Payment

Physical and occupational therapists do this consultation work constantly and without payment. A PT collaborating with a primary care physician about a patient’s fall risk, functional trajectory, and home environment is doing exactly the interprofessional consultation for which these behavioral health codes were designed to compensate. 

An OT consulting with a patient’s primary care team about home modification needs, adaptive equipment, and the functional limitations driving that patient’s risk of institutionalization is doing the same category of work. They are providing expert clinical input delivered to another provider, outside a face-to-face visit, that shapes the overall plan of care.

The Gap These Codes Do Not Fill

This is categorically different from the caregiver training codes (97550–97552) that CMS added in 2024. This was a genuine advocacy win that pays PTs and OTs to train family caregivers in strategies to support the patient’s treatment plan. Those codes address provider-to-caregiver instruction. 

The interprofessional consultation model addresses provider-to-provider consultation. That’s a PT or OT delivering expert functional health input to a physician, case manager, or care team member who is making clinical decisions about a shared patient. That work has no billing pathway. We do it now, for free, because we believe it is part of good patient care. That is precisely what these codes would change.

The Ask

The parallel G-code structure CMS built for behavioral health is the template we bring to CMS directly. The clinical rationale maps cleanly, the precedent is less than two years old, and the framing is simple:

CMS recognized that behavioral health providers deliver valuable non-face-to-face consultation and coordination work that improves patient outcomes and reduces the burden on the primary care team. So they created a payment pathway to incentivize it.

Physical and occupational therapists deliver the same category of work on the functional health side of the primary care team.

The ask is not new ground. It is just the next application of a principle to which CMS has already committed.

Lever 7: Care Coordination, Remote Therapeutic Monitoring, and Telehealth

Care Coordination: The Invisible Work That Holds Care Together

Care coordination codes represent one of the most glaring structural inequities between how CMS treats physical and occupational therapists and how it treats primary care providers. Physicians can bill for coordinating care across the healthcare system, communicating with patients between visits, and managing complex patients. 

Therapists do all of this work without a billing pathway, or they don’t do it as often as they might because they don’t have a billing pathway. The creation of therapy-specific care management and coordination codes is both clinically justified and administratively feasible within CMS’s HCPCS coding authority.

A related near-term opportunity exists through Advanced Primary Care Management (APCM) codes (G0556–G0558), effective January 1, 2025. APCM codes are billed by the physician or non-physician practitioner who serves as the patient’s primary care focal point for medical care. It entails one claim per patient per month. Importantly, CMS allows APCM services to be provided by clinical staff and auxiliary personnel working under the direction of the billing clinician.

So a PT or OT who is embedded in a primary care practice can deliver APCM-eligible services, including functional assessment, care coordination, and caregiver support as part of the interprofessional team, contributing to a billable APCM service under the physician’s claim.

This is not a separate billing pathway for therapists in their own clinics. It is simply a practice integration model that creates immediate demonstrable value within primary care while building the outcome data that supports future independent billing arguments. Practice owners who are exploring primary care partnerships should be aware that this infrastructure exists today within that context.

Remote Therapeutic Monitoring and Building on it Thoughtfully 

Remote therapeutic monitoring was a genuine win for the therapy profession when the codes were introduced in 2022, creating the first billing pathway for the kind of longitudinal, between-visit engagement that characterizes true primary care team membership. The 2026 PFS final rule expanded the framework meaningfully, adding new codes that lower the monitoring threshold from 16 days to as few as 2 days in a 30-day period, and introducing a new 10-minute treatment management code that reduces the previous 20-minute requirement. CMS’s message in finalizing these changes is that it views RTM as a maturing, expanding framework aligned with its digital health and hybrid care priorities. 

It is also worth noting that some payer scrutiny of RPM/RTM billing practices has been seen alongside adoption, and CMS explicitly reiterated in the 2026 rule that medical necessity must be documented for every patient enrolled. The profession’s credibility with RTM, and our ability to advocate for its continued expansion, depends on using it with exactly the clinical integrity and documentation discipline it requires. RTM used well, with clear outcome data attached, is one of the most persuasive proof points we can bring to every other ask on this list.

The near-term advocacy within CMS’ rulemaking authority is modest and defensible: continued refinement of documentation requirements to reduce administrative burden without reducing accountability, and thoughtful expansion to additional conditions and populations where the clinical evidence supports it.

Telehealth: Current Status and the Path to Permanence

Telehealth permanence requires congressional action and remains the outstanding legislative priority, but the immediate situation is more stable than it has been in years. The Consolidated Appropriations Act of 2026, signed February 3, 2026, extended PT and OT telehealth eligibility. It did so along with all major Medicare telehealth flexibilities including home as originating site, no geographic restrictions, and audio-only coverage, all through through December 31, 2027. 

That two-year window is meaningful breathing room, but it is not permanence. 

The profession has now lived through enough telehealth cliffs to know that waiting for the next extension is not a strategy. The CONNECT for Health Act of 2025 (H.R. 4206 in the House, S. 1261 in the Senate) would make the current flexibilities permanent and has accumulated strong bipartisan support. This is the active vehicle for permanence and our associations should be actively supporting it. 

In the meantime, the documentation, coding, and coverage criteria for tele-rehab are within CMS’s regulatory lane. This makes the administrative framework as clean and clinically appropriate as possible and is a CMS ask worth pursuing every comment cycle while the congressional permanence effort continues.

The clinical case for tele-rehab is multi-faceted. But it’s not simply about convenience. In the longitudinal care model we are arguing for, telehealth visits can serve a categorically different function than in-person care based on patient needs and preferences. A check-in visit to review a home program, assess adherence, make minor plan adjustments, and maintain the therapeutic relationship does not require the patient to drive to a clinic. 

For an older Medicare beneficiary with transportation challenges, a caregiver managing competing demands, or a patient in a rural area with limited access, that flexibility is often the difference between staying engaged with care and dropping out entirely. Tele-rehab is not a lesser version of therapy. For the right visit type and the right patient, it is the right tool.

The Complete Toolbox: Why All of These Matter Together

That last point is worth stating plainly as the organizing principle for this entire lever. 

What therapists need is a complete toolbox. 

In-person care for the visits that require hands-on assessment, manual techniques, and direct functional observation. 

Telehealth for the check-ins, education, and plan management that sustain the longitudinal relationship between higher-touch visits. 

RTM to monitor adherence, detect early functional changes, and maintain clinical presence between visits without requiring synchronous contact. 

Care coordination codes to compensate for the behind-the-scenes communication and team integration that keeps the broader care team aligned. 

No single modality serves every patient’s need at every point in an episode.

The practices that can move fluidly across all of these by matching the right touchpoint to the right clinical moment will deliver better outcomes, higher engagement, and lower total cost of care. That is the model CMS says it wants to build toward. These codes, expanded and properly valued, are what make it operationally possible for therapy.

Lever 8: MPPR Reform Through Rulemaking and Congressional Backstop

Understanding the History

The Multiple Procedure Payment Reduction (MPPR) applies a 50 percent reduction to the practice expense component of the second and subsequent timed therapy procedures provided in a single session. Understanding its history is important for knowing how to argue against it effectively.

The MPPR originated in 1995 applied to nuclear medicine procedures, was extended to diagnostic imaging services in 2006, and was extended to therapy services in 2011. It was done on the theory that when multiple services are furnished together, certain practice expense activities like patient preparation and equipment setup occur only once and should not be paid twice. 

That theory holds reasonably well for imaging and procedural services where a technician sets up equipment once for multiple scans. It does not hold for therapy. There is no meaningful shared setup between a unit of therapeutic exercise and a unit of neuromuscular reeducation. The clinician is the setup, and that engagement does not diminish with the second procedure.

The 50 percent rate applied to therapy was then locked in by Section 633 of the American Taxpayer Relief Act of 2012, effective April 1, 2013. That congressional action complicates the picture somewhat. Here’s why:

While CMS applied the MPPR to therapy through rulemaking in 2011 using its authority under Section 1848(c)(2)(K) of the Social Security Act to identify potentially misvalued bundled codes within the Physician Fee Schedule, Congress subsequently hardened the specific rate through legislation.

The Two-Track Strategy

This means that while CMS retains authority over how the MPPR is applied and structured, fully eliminating the 50 percent therapy rate likely requires either: 

• CMS concluding through rulemaking that the existing application is no longer justified, or 
• Congress acting to remove or modify the rate it set. 

We need to create a plan with eyes open about that distinction.

The Practical Effect of the MPPR is Perverse Regardless of its Origin. 

Comprehensive, efficient sessions that address multiple, related deficits in an integrated way are financially penalized relative to single-modality sessions. This creates an incentive toward fragmented care and higher visit frequency, which is exactly the model that payers and patients find least valuable. It also runs counter to the prevention-focused, patient-centered care CMS says it wants to incentivize.

The two-track strategy: 

• Pursue CMS through the annual comment period with time-motion data, evidence on integrated session outcomes versus fragmented care, and total visit count comparisons that demonstrate the MPPR creates misaligned incentives inconsistent with CMS’s stated priorities. 
• Simultaneously pursue a congressional appropriations rider or standalone legislation to modify the rate Congress set in 2012.  

Both tracks are worth running in parallel, and the CMS record you build through comment letters and other engagement strengthens the congressional argument.

Lever 9: Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) — A Congressional Target Worth Pursuing

The Current Gap and Why It Matters

This lever requires congressional action, but it is worth naming explicitly. The precedent is partially established, and the argument has grown stronger since the last time it was formally pursued.

Physical and occupational therapists are not currently covered as standalone billable services under the FQHC or RHC Medicare benefit for routine outpatient therapy. That exclusion has real consequences for access: FQHCs and RHCs serve underserved communities, low-income populations, and rural areas where therapy access is most limited and where the functional health burden is often highest. 

The Physical Therapist Workforce and Patient Access Act has been introduced in every Congress since 2019. The 118th Congress version proposed adding PT to the FQHC and RHC Medicare benefit and also included National Health Service Corps loan repayment eligibility for physical therapists. It was referred to the House Subcommittee on Health in July 2023 and never received a hearing. A 2025 version has been introduced in the 119th Congress and is currently pending in the same committees.

Two things need to change about how this bill is pursued. 

First, it has stalled at the subcommittee stage repeatedly, which means the missing ingredient is not the legislation. What’s probably missing is the physician champion relationships, the ACO and rural health organization co-sponsors, and the committee member engagement that gets a bill from referral to hearing. 

Second, occupational therapy has been absent from every version of this bill, which is both a policy error and a strategic one. A bill that includes both PT and OT is a stronger bill. It has a broader coalition, broader access argument, and includes more constituents. Any future version should include both professions from the start.

Why the Argument Is Stronger Now

What makes the argument stronger now than it was when that bill was introduced is what Congress did in 2023. The Consolidated Appropriations Act of 2023 created the Intensive Outpatient Program benefit at FQHCs. Occupational therapy was explicitly designated as a required service within that benefit, effective January 1, 2024. Congress has already determined that OT is essential enough to mandate it within a specific FQHC mental health benefit. 

The logical and defensible next step is recognizing standalone PT and OT as coverable FQHC services more broadly, and to do so not as a new idea, but as the natural extension of a recognition Congress has already made. That is a stronger legislative argument than starting from scratch, and our associations should be framing it that way.

RHC and FQHC inclusion pairs naturally with rural access and health equity/social drivers of health arguments that have genuine bipartisan traction. In addition, the cost-based reimbursement structure of these settings means the ask does not carry the same PFS budget neutrality obstacle that most other levers do. It belongs in our congressional engagement alongside MPPR reform legislation and telehealth permanence. Given the IOP precedent, it may be closer to achievable than it appears.

Getting Into the Room: A Strategy for Real Influence

Most therapists are not in the rooms where the policy decisions that affect our future are made. 

We are not publishing in Health Affairs. We are not presenting at accountable care, value-based care, or primary care coalition and trade association conferences. We are not regularly engaging proactively in the CMS rulemaking process with the kind of organized, evidence-based advocacy that behavioral health providers, primary care physicians, and hospital systems make routine. That has to change.

Win Primary Care as Champions

Primary care physicians and advanced practice providers must be our champions in policy spaces because policymakers are oriented around primary care as the anchor of the healthcare delivery system. When a Family Medicine organization supports a therapy policy ask, it lands differently than when therapy associations make the same ask alone.

The American Academy of Family Physicians, the American College of Physicians, professional associations for nurse practitioners and physician associates, and similar organizations are our natural allies — but only if we approach them with a pitch that solves their problems, not ours.

Here is the problem we solve for them: 

A primary care physician who sees 20 to 25 patients a day has roughly 15 to 20 minutes per visit. When a patient presents with low back pain, a fear of falling, declining function after a hospitalization, or hand weakness limiting their independence, the physician faces a choice between managing it inadequately in the time available or referring out to a specialty physician that is slow, expensive, and disconnected from the primary care relationship. Even if they refer to therapy in our current structure, which is mostly silo’d, the success rate for patients actually presenting to therapy is very low. Neither outcome serves the patient or the physician. 

Primary care physicians are overwhelmed with patients who have chronic pain, balance problems, functional decline, fine motor impairments, and musculoskeletal complaints that they do not have the training or time to address. That is not a complaint about primary care. It is a structural gap that we are trained and positioned to fill.

An embedded, near site, or closely affiliated therapy provider gives the primary care practice a functional health resource that handles the referrals that were previously going nowhere productive. Patients whose functional needs are being actively managed require fewer problem visits, freeing physician time for the medical complexity that genuinely requires a physician or other primary medical provider.

For practices operating in value-based care arrangements such as accountable care organizations (ACOs), the economic case is direct. It results in lower downstream utilization means lower total cost of care. Fewer imaging orders, fewer injections, fewer emergency visits, fewer hospitalizations from falls that were never addressed. That translates into shared savings the ACO can actually realize.

There is also a quality measure argument that is increasingly urgent. CMS and commercial payers are holding primary care practices accountable for fall prevention, functional status, and chronic pain management outcomes. These are not physician training domains. They are ours. 

A primary care practice with an embedded musculoskeletal and functional health partner performs better on the measures that are increasingly tied to their own reimbursement. The Medicare Annual Wellness Visit is a natural entry point. Physicians are already expected to screen for fall risk and functional decline, and most do not have a reliable referral pathway that resolves those findings. We are that pathway.

Our advocacy pitch to primary care organizations is not “support our reimbursement.” It is: “Let us be embedded in and/or a direct extension of your team. Here is the clinical case, the economic case, and the operational model. Let’s build this together and tell CMS about it jointly.”

Publish Where Policymakers Read

Health Affairs is a key publication that shapes health policy discourse in Washington. When an idea appears there, it enters the conversation that CMS officials, congressional staff, think tank researchers, and health system executives are already having. 

PT and OT research in Health Affairs that includes topics like policy analyses, original research, and perspective pieces signals that our profession is a serious participant in that conversation. NEJM Catalyst, JAMA Health Forum, and Milbank Quarterly, are examples of other publications that serve similar functions.

A well-argued 1,500-word perspective piece making the case for a functional assessment G-code, co-authored with a primary care physician, may even have more policy impact than a dozen congressional visits. At the very least, they complement each other beautifully. That’s a strategy other professions routinely employ. 

We need to be writing in the right places about cost savings from MSK-first pathways, the ROI of functional assessment, the evidence for therapy integration in ACOs, the policy case for interprofessional consultation access, and more.

Engage the VBC and ACO Community

ACOs — particularly those in the Medicare Shared Savings Program, ACO REACH, and the emerging LEAD model — are actively managing total cost of care for attributed beneficiaries. MSK conditions are among their highest-cost categories. Fall-related hospitalizations are among their most expensive and unpredictable events. These organizations have strong financial incentives to care about what we offer, but most have not been approached with a concrete, operationally actionable proposal from a therapy practice.

The LEAD model, the ACO REACH successor launching in 2027, represents a significant opportunity. Practice owners who become fluent in value-based care language — total cost of care, utilization management, risk stratification — and who show up at National Association of ACOs meetings and primary care value-based care conferences will be in the right rooms at the right time. Preferred provider relationships, shared savings arrangements, and outcome-based partnerships with ACOs can be structured now, generating proof points that advance every other ask on this list.

Engage the CMS Formal Process Every Year

Every year, CMS publishes a proposed rule for the Physician Fee Schedule and accepts public comments. CMS staff read substantive comments. Organized, evidence-based, well-framed comments from providers influence final rules. When behavioral health advocates submitted years of organized comments in support of new codes and RVU increases, CMS responded. The process works when we use it and take it seriously.

Practice owners who submit individual, substantive comments that include real arguments with real data add meaningful weight to association advocacy. CMMI runs regular requests for information and stakeholder engagement processes when designing new models. Getting a therapy practice leader into a CMMI stakeholder call is not impossible. It requires knowing those calls exist and showing up prepared. Our associations may be able to facilitate greater CMMI engagement opportunities for practice owners as a matter of routine.

Practice Owners, This is a Call to Action to Lead the Charge

The future of this profession cannot be shaped without practice owners and clinic leaders. This point is the recognition of structural reality. Staff therapists are focused on patient care, managing documentation, often juggling significant student debt, and operating within systems that do not reward policy engagement. They deserve a future worth working toward. Creating that must be led by those with the platform, the resources, and the skin in the game to engage the system that determines whether that future is possible.

If you own a therapy practice of any kind or size, such as a solo clinic, a multi-site group, or an integrated practice, the stakes could not be higher. Fee-for-service, as currently structured, is not a viable long-term model for most private therapy practices. The national therapy chains that tried to solve this through volume are cautionary tales. 

Volume does not work in a declining reimbursement environment. What works is value, and demonstrating value requires engagement with the policy and payment systems that determine how value is defined and rewarded.

Here is what practice owners need to be doing starting today, especially if they are not at all engaged right now:

• Learn the policy landscape deeply enough to engage it. This blog series is a starting point, not an endpoint. Subscribe to Health Affairs. Follow APTA and AOTA policy briefings. Read the annual PFS proposed rule summaries. Understand the difference between CMS rulemaking authority and congressional statutory authority. Know what the HCPAC is and what your associations are submitting through it.
  
• Standardize outcome measurement in your practice now. You cannot build an evidence base without data. Choose validated instruments, collect them consistently, and track outcomes across your patient population. This is the foundation of every other advocacy ask on this list.
  
• Build one real, value-based relationship outside of therapy. A primary care clinic. An ACO. A VBC organization. A hospital care management team. Learn what they care about and how you can solve their problems. An example is to ask about APCM and whether there is a role for your team to contribute as part of their care management infrastructure. 
  
• Submit substantive CMS comment letters every year. The annual PFS comment period is a direct regulatory channel. Make specific, evidence-backed asks framed in CMS language. Reference the G0136 precedent, the behavioral health G-code model, and the MedPAC PE recommendation. Build a record. 
  
• Engage and fund your associations’ policy work. The work APTA, AOTA, APTQI, and others do requires resources and direction. Show up at state chapter meetings. Volunteer for advocacy committees. Participate in stakeholder processes when your associations invite it. Your associations are only as powerful as the profession behind them.
  
• Talk to your employees about the future honestly. Attrition is high in therapy partly because the reality of practice does not match what clinicians were trained to believe was possible. Be explicit about the challenges and the vision you are working toward. The best therapists want to work for practices that are building something meaningful.

A Realistic Timeline: What Progress Actually Looks Like

Let’s be specific about timelines and not just vague aspirationalism. Here is a realistic sequence, grounded in how CMS rulemaking, CMMI model development, and coalition-building actually work.

Now to 3 Months: Build Fluency and Internal Infrastructure

• Share this blog series with your leadership team and have an explicit conversation about what the policy landscape means for your practice model.
• Choose one standardized functional outcome measure to collect consistently across your patient population starting now, if you aren’t already.
• Draft your two-minute elevator pitch: “We help primary care succeed by addressing the functional drivers of health that physicians don’t have time to manage. Here is the evidence and here is the operational model.”
• Identify one non-therapy organization, such as a primary care clinic, ACO, or VBC group, to start learning about and building a relationship with.

3 to 12 Months: Produce Proof and Build Relationships

• Pilot a functional assessment pathway. Document outcomes. Track downstream utilization wherever possible.
• Attend one non-therapy conference: a primary care summit, an ACO stakeholder meeting, or a VBC event.
• Submit a substantive comment letter on the annual PFS proposed rule. Use data. Make specific asks. Reference the G0136, behavioral health G-code, and MedPAC PE recommendation precedents explicitly.
• Connect with your state chapter leadership. Ask what formal CMS engagement is planned and where individual practice owners can contribute data or testimony.

12 to 36 Months: Translate Proof Into Policy Momentum

• Partner with a primary care organization or ACO to publish outcome data — even a brief case study or white paper builds the evidence base that policy arguments require.
• Pursue a preferred provider or shared-savings arrangement with a local ACO or LEAD-participating primary care group. Learn the model. Develop a concrete operational proposal.
• Work with your associations to develop formal proposals for functional assessment G-codes, a therapy-specific longitudinal complexity add-on code, interprofessional consultation codes, and PE modernization, and submit through every available CMS channel, including HCPAC.
• Co-author a policy perspective, such as a Health Affairs brief, a NEJM Catalyst piece, with a primary care physician or ACO leader. The co-authorship is the point. 

This path is not linear. There will be fee schedule cycles that disappoint. There will be political environments that are more or less receptive. The professions that win are the ones that stay engaged through all of that. They are building proof points, building relationships, and refusing to accept that the status quo is the only available future.

CMMI: The Lever We Cannot Afford to Ignore — And What’s Coming in Blog 3

We have threaded CMMI throughout this playbook because it deserves to be understood for what it is: Arguably the most powerful single lever available to the therapy profession right now, and the one we are most systematically underusing.

CMMI has statutory authority to test new payment models without requiring congressional action. It has the budget through mandatory spending to fund those models outside PFS budget neutrality constraints. 

And models that demonstrate savings, which are those that achieve at least the no-worse-outcomes, lower-cost threshold, can be expanded nationwide by the HHS Secretary. Those that meet the criteria can potentially become permanent Medicare policy without a single floor vote in Congress. 

CMMI models that already include therapists, even if indirectly, are pointing the way: GUIDE for dementia care, TEAM for total joint replacement, and the emerging LEAD model that creates new opportunities for primary care organizations to partner with other providers with the support of CMS.

These models represent the proof-point engine that makes every other ask on this list easier. 

Engaging CMMI is not extra credit. 

Engaging CMMI is the way to build robust evidence that makes profession-altering change possible.

In our next and final blog in this series, we go deep on CMMI. We will include much more about how it works, which active and emerging models matter most for PT and OT, how to engage the model design and stakeholder process, what a preferred provider relationship with a LEAD-participating primary care organization might look like, and what the realistic path is toward getting therapy systematically embedded in value-based care models that generate both proof points and meaningful revenue.

CMMI is a major lever. It will require learning and sustained engagement. And it may be the most important strategic investment this profession can make right now.

We’ll see you in Blog 3.

A note on sources and verification: This blog is part of a three-part series on the future of PT and OT policy, published on OT Potential. Blog 1, “The Therapy Reimbursement Guide,” covers the history and mechanics of PT and OT payment under Medicare — read it before this one. Blog 3 will cover CMMI models and value-based care participation. 

Statutory citations refer to Sections 1848 and 1861 of the Social Security Act (42 U.S.C. §1395w-4 and §1395x). The HCPAC description draws on AMA RUC documentation. The 2025 behavioral health G-code descriptions refer to G0546–G0551, effective January 1, 2025. APCM codes G0556–G0558 are effective January 1, 2025. The CAA of 2026 telehealth extension was signed February 3, 2026. The CONNECT for Health Act of 2025 is H.R. 4206 / S. 1261. APTA’s 2026 PFS final rule PE survey report should be linked at publication. CMMI model details are available at innovation.cms.gov.

Disclaimer: This playbook is intended for informational and planning purposes only and does not constitute legal advice. It was not prepared by an attorney and should not be relied upon as a substitute for professional legal or regulatory counsel. Recommendations and examples are offered as starting points for consideration; any action taken should follow a comprehensive, context‑specific review by qualified advisors. The authors and distributors accept no responsibility for decisions or actions taken based on the material in this document.