G4026 Physical/Occupational Therapy MIPS Reimbursement | OpenPayer

Summary & Overview

HCPCS G4026: Physical Therapy/Occupational Therapy MIPS Specialty Set

HCPCS Level II code G4026 designates the Physical therapy/occupational therapy MIPS specialty set, a reporting category used by clinicians to submit performance measures under MIPS. Nationally, this code supports quality reporting and performance assessment for physical and occupational therapy providers participating in federal value-based payment programs and aids payers and organizations in tracking specialty-specific measures.

Key payers addressed include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. The code matters because specialty MIPS sets help align rehabilitative therapy reporting with broader quality and reimbursement frameworks, influencing comparative performance metrics and program participation requirements across payers.

Readers will learn what G4026 represents, which payers typically consider in comparative analyses, and the clinical and administrative context for its use. The publication provides benchmarks and implementation context where available, summarizes relevant policy considerations for specialty measure reporting, and outlines the typical settings where the code is applied. Data not available in the input is noted where applicable.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicareG4026HCPCS Level IIphysical therapyoccupational therapyMIPSquality reportingperformance measuresoutpatient therapy

Billing Code Overview

HCPCS Level II code G4026 represents the Physical therapy/occupational therapy MIPS specialty set. This code identifies a specialty measure set used for reporting performance under the Merit-based Incentive Payment System (MIPS) specific to physical therapy and occupational therapy clinicians.

Service type: Performance measurement/reporting for physical therapy and occupational therapy clinicians
Typical site of service: Outpatient therapy practices and other clinical settings where physical therapy and occupational therapy services are furnished and clinicians participate in MIPS

Clinical & Coding Specifications

Clinical Context

A typical patient scenario involves an adult referred for measurement and reporting of physical therapy or occupational therapy quality measures under the MIPS specialty set. For example, a 68-year-old patient discharged from hospital care after a left total knee arthroplasty is scheduled for outpatient physical therapy to improve range of motion, gait, and functional mobility. The clinical workflow begins with a PT evaluation visit where the therapist documents baseline functional status, pain level, and mobility limitations; selects appropriate evidence-based interventions; and records standardized outcome measures required by the MIPS therapy specialty set. Subsequent visits include progression of therapeutic exercises, manual therapy as indicated, balance and gait training, periodic re-assessments using standardized outcome instruments, and electronic reporting of selected MIPS measures for performance feedback and quality reporting. Typical documentation includes evaluation and plan of care, timed or untimed therapeutic procedure notes, progress notes, outcome measure scores, and any communication with the referring surgeon or primary care provider.

Coding Specifications

Modifier	Description	When to Use
`22`	Increased procedural services	Use when the therapy session required substantially greater clinical effort or documentation than typical (e.g., unusually complex evaluation or extended treatment beyond usual complexity).

HCPCS G9822: Endometrial Ablation Within Prior 12 Months

HCPCS-G0144-CERVICAL-VAGINAL-CYTOLOGY-AUTOMATED-THIN-LAYER-SCREENING

HCPCS G0144: Cervical or Vaginal Cytopathology Screening, Automated

HCPCS-G8809-RHOGAM-ORDERED-IMMUNOPROPHYLAXIS

HCPCS G8809: Rh-immunoglobulin (Rhogam) Ordered

HCPCS-G9111-HEAD-AND-NECK-SQUAMOUS-CELL-DISEASE-STATUS

HCPCS G9111: Head and Neck Squamous Cell Cancer Disease Status

HCPCS-G9128-MULTIPLE-MYELOMA-DISEASE-STATUS-SMOLDERING-STAGE-I

HCPCS G9128: Multiple Myeloma Disease Status Assessment, Smoldering/Stage I

HCPCS-G2021-TREATMENT-IN-PLACE-TIP

HCPCS G2021: Health Care Practitioners Rendering Treatment in Place (TIP)

HCPCS-G0476-HPV-HIGH-RISK-NUCLEIC-ACID-DETECTION-CERVICAL-SCREENING

HCPCS G0476: HPV High-Risk Nucleic Acid Detection for Cervical Screening

HCPCS-G9662-ESTABLISHED-ASCVD-DIAGNOSIS-PROCEDURE-HISTORY

HCPCS G9662: Previously Diagnosed Clinical ASCVD, Including ASCVD Procedure

HCPCS-G8956-MAINTENANCE-HEMODIALYSIS-OUTPATIENT-DIALYSIS

HCPCS G8956: Maintenance Hemodialysis in Outpatient Dialysis Facility

HCPCS-G8844-AHI-RDI-REI-NOT-DOCUMENTED-AFTER-INITIAL-OSA-EVALUATION

HCPCS G8844: Missing AHI/RDI/REI Documentation After Initial OSA Evaluation

Showing 1–10 of 1996

Taxonomy Code	Specialty	Notes
`225100000X`	Physical Therapist	Primary provider specialty performing outpatient PT services and MIPS specialty set reporting.
`225200000X`	Occupational Therapist	Provides OT assessments and interventions included in therapy MIPS measures.
`206E00000X`	Physical Therapy Assistant	Supports delivery of therapy under PT direction; documentation must reflect supervisory model.
`206D00000X`	Occupational Therapy Assistant	Assists in OT interventions under OT direction; relevant for billing and documentation.
`364S00000X`	Rehabilitation Specialist	Physicians or specialists coordinating multidisciplinary rehab plans and MIPS reporting.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`M17.11`	Unilateral primary osteoarthritis, right knee	Common indication for postoperative outpatient physical therapy after knee arthroplasty; relevant to functional outcome measures.
`M17.12`	Unilateral primary osteoarthritis, left knee	Same relevance for left knee arthroplasty rehabilitation and MIPS therapy reporting.
`S83.241A`	Bucket-handle tear of medial meniscus, right knee, initial encounter	Indicative of patients receiving structured PT/OT for recovery and functional restoration.
`S72.001A`	Fracture of unspecified part of neck of right femur, initial encounter for closed fracture	Rehabilitation after lower-extremity fracture often generates PT/OT services tracked in the MIPS specialty set.
`G81.11`	Hemiplegia affecting right dominant side	Neurologic deficits requiring intensive PT/OT and standardized outcome reporting under specialty measures.
`M54.5`	Low back pain	Common condition managed with PT interventions included in quality reporting sets.
`R26.89`	Other abnormalities of gait and mobility	Functional impairment commonly addressed in therapy sessions and tracked by outcome measures.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`97110`	Therapeutic exercises to develop strength, endurance, range of motion and flexibility (each 15 minutes)	Commonly performed during physical therapy episodes reported in the MIPS specialty set; used for active strengthening and ROM interventions.
`97112`	Neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and proprioception (each 15 minutes)	Frequently used for gait and balance retraining post-orthopedic surgery within the therapy MIPS measures.
`97116`	Gait training (includes stair training) (each 15 minutes)	Directly related to functional mobility goals documented in PT evaluations and MIPS reporting.
`97140`	Manual therapy techniques (e.g., mobilization/manipulation, manual lymphatic drainage) (each 15 minutes)	Used as adjunctive treatment during therapy episodes captured by the MIPS specialty set.
`97530`	Therapeutic activities, direct (one-on-one) patient contact (each 15 minutes)	Common occupational therapy or physical therapy functional training code used during MIPS-related care.
`97035`	Ultrasound therapy (thermal)	Modalities occasionally used adjunctively and documented in the plan of care for MIPS quality reporting.

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