CPT code 97026: Infrared therapy billing, documentation and reimbursement

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Key takeaways

CPT code 97026 describes the supervised application of infrared therapy, a physical medicine modality that does not require constant clinician attendance during treatment.

Medicare rules infrared therapy non-covered nationally under NCD 270.6, so no local contractor policy can pay for CPT code 97026 in the excluded conditions.

Documentation must capture the treatment area, duration, clinical indication, and medical necessity rationale. Missing any element is a leading cause of claim denial for this code.

For a Medicare patient, an Advance Beneficiary Notice signed before treatment is what lets the practice bill the patient after the expected denial.

Pabau’s claims management software links infrared therapy records directly to billing submissions, which cuts manual code entry and denial risk on supervised modality codes.

CPT code 97026 is classified under the Physical Medicine and Rehabilitation section of the AMA CPT codebook, within the supervised modalities subsection (codes 97010-97028). The official descriptor reads: Application of a modality to one or more areas; infrared.

Coverage is the part worth settling first. Medicare treats infrared therapy as nationally non-covered under national coverage determination (NCD) 270.6. So payment on a 97026 claim usually comes from a commercial payer, a workers’ compensation carrier, or the patient.

The supervised designation is the most clinically significant aspect of CPT code 97026 for billing purposes. Under CMS guidelines, supervised modalities allow the qualified provider to monitor several patients at once without maintaining one-on-one contact during the procedure.

This contrasts with “constant attendance” modalities, which require the provider to be present throughout. Infrared therapy falls into the supervised category because the device delivers treatment autonomously once applied.

Clinically, infrared therapy uses wavelengths in the 700 nm to 1 mm range to penetrate superficial tissue. That promotes vasodilation, reduces muscle spasm, and supports pain management. Providers use it for musculoskeletal conditions, wound healing support, and pain relief in rehabilitation.

Who can bill CPT code 97026?

CPT code 97026 may be billed by qualified rehabilitation providers in both outpatient and practice settings. Eligibility varies by state licensure and payer credentialing, so confirm your own payer contracts before billing.

• Physical therapists (PTs) — the primary billing provider for infrared therapy in most outpatient rehabilitation settings
• Occupational therapists (OTs) — eligible where infrared supports functional rehabilitation goals written into the plan of care
• Chiropractors (DCs) — frequently bill 97026 alongside spinal manipulation codes in musculoskeletal care
• Physicians and mid-level providers — eligible when supervising or directly providing physical medicine services. Check payer-specific rules for incident-to billing.
• Therapy assistants (PTAs and OTAs) — may apply the modality under qualifying supervision. Reimbursement can be reduced under Medicare’s assistant differential payment rules.

Facility type matters. Hospital outpatient departments, private practices, and chiropractic offices bill this code under different Medicare rate structures. Confirm whether the facility or non-facility rate applies to your setting before you quote a fee to a patient.

Documentation requirements for infrared therapy

Insufficient documentation is the leading cause of denial for CPT code 97026. Most payers require specific elements in the clinical record to support medical necessity. A vague note like “infrared applied to lower back” will not survive a payer audit.

• Diagnosis with ICD-10-CM code — link the primary diagnosis to a code that supports infrared therapy. Musculoskeletal pain and soft tissue injury are the usual examples.
• Treatment area — specify the anatomical region treated, such as lumbar spine, bilateral shoulders, or right knee
• Duration — record the length of each infrared application. The code is billed per application rather than per time unit, but duration still supports medical necessity.
• Medical necessity rationale — a clinical statement explaining why infrared therapy suits this patient at this stage of treatment
• Provider credentials — the supervising clinician’s name, license type, and signature, which Medicare audits and incident-to billing both require
• Treatment plan reference — the infrared application should trace back to the patient’s plan of care, rather than sitting in the note as a standalone entry
• Response to prior treatment — for an ongoing course, record how the patient is responding, because payers look for evidence of clinical progress

Capturing these elements at the point of care costs less than reconstructing them for an appeal. A clean claim for 97026 needs every one of them present and legible before the claim leaves the practice.

Medicare coverage for CPT code 97026

Medicare does not cover CPT code 97026 for the indications practices most often want to bill. National coverage determination (NCD) 270.6 rules infrared and near-infrared therapy non-covered, and it has been in force since 2006.

NCD 270.6 names the excluded conditions directly. They are diabetic and non-diabetic peripheral sensory neuropathy, plus wounds and ulcers of the skin and subcutaneous tissue, including the pain arising from them. An NCD binds every Medicare Administrative Contractor (MAC). So no local coverage determination (LCD) from Novitas Solutions, National Government Services, or any other contractor can restore coverage for those indications.

General musculoskeletal pain sits outside NCD 270.6, but it has no national coverage authority behind it either. Coverage there falls to each contractor’s own policy, and most treat supervised infrared as not medically necessary. Either way, the practical answer for a Medicare patient is the same.

An ABN is the practical answer here. Signed before treatment, it tells the patient that Medicare will probably not pay and lets the practice collect the fee directly. Without one on file, a denied 97026 claim leaves the practice with no compliant route to bill the patient.

Private insurance and commercial payer coverage

Commercial payer coverage for CPT code 97026 is more variable than Medicare, and in some cases more favorable. Many commercial plans do cover infrared therapy for musculoskeletal indications where Medicare does not. They impose their own conditions, such as prior authorization, visit limits, or diagnosis-specific criteria.

Workers’ compensation payers tend to be the most permissive for infrared therapy billing. State-mandated fee schedules govern the rates, and the coverage restrictions are generally lighter than Medicare’s. Auto insurance and personal injury cases may also reimburse 97026 under medical payment provisions.

Verify benefits and prior authorization with the specific plan before each course of treatment. Some plans require a treating diagnosis from an approved list. Others simply want a physician referral and a documented plan of care.

Put the payers side by side and the pattern is clear. The billing decision on 97026 is made before the first application, not after the remittance advice arrives.

Reimbursement rates and the fee schedule

Reimbursement for CPT code 97026 varies by geographic location, payer type, and facility setting. The Medicare non-facility rate sits at roughly $7 to $12 per application. That figure shifts with annual RVU updates and Geographic Practice Cost Index (GPCI) adjustments. Verify the current rate for your locality and year on the CMS fee schedule search.

Because CPT code 97026 carries a low reimbursement rate, the revenue per visit is marginal when the code is billed on its own. Its value is highest inside a documented, medically necessary plan of care that also includes higher-paying timed codes. Therapeutic exercise (97110) and therapeutic activities (97530) are the usual companions, where NCCI edits permit co-billing.

Related CPT codes in the 97000 series

CPT code 97026 belongs to a family of supervised physical medicine modality codes. Knowing where it sits in the 97000 series helps coders pick the right code and avoid upcoding an adjacent procedure. The table below groups the series by supervision type and billing unit.

The key difference between CPT code 97026 and codes like 97032 or 97035 is supervision versus constant attendance. Constant attendance codes require the provider to stay with the patient throughout, which makes them higher-value and more demanding to document. Billing 97026 when the provider stayed with the patient throughout, or the reverse, is a common audit finding that leads to recoupment.

Bundling rules and compatible codes

The National Correct Coding Initiative (NCCI), administered by CMS, governs which CPT codes can be billed together on the same date of service. Several bundling principles apply to CPT code 97026 before you submit a multi-code claim.

Key bundling rules for 97026:

• Two supervised modality codes on the same date, such as 97010 and 97026, are generally billable when they treat different areas or represent distinct services. Payers vary, so check your own payer’s NCCI edits.
• 97026 and the constant attendance codes 97032 and 97035 may share a date of service when the services are genuinely separate and documented separately.
• 97026 should not be billed with 97028 (ultraviolet) on the same area in the same session. Most payers treat that as unbundling.
• Therapeutic exercise (97110) and therapeutic activities (97530) are generally compatible with 97026, since infrared is usually applied before the active therapeutic work.

NCCI edits update quarterly, so verify current bundling rules against the CMS NCCI Policy Manual rather than prior-year guidance. The AAPC Codify CPT lookup gives a practical crosswalk for checking code compatibility. It also shows the modifier indicators that allow billing an otherwise bundled pair when documentation supports separate services.

Common billing errors and how to avoid them

The denials and audit findings that follow CPT code 97026 come from a short, predictable list. Standardized documentation catches almost all of them before the claim goes out.

• Insufficient medical necessity documentation — billing 97026 without a clinical rationale in the treatment note. This is the most common denial reason across payers for this code.
• Incorrect supervision designation — applying constant attendance documentation standards to a supervised code. The reverse error also happens, where a supervised modality is billed although the record shows the provider stayed with the patient.
• Billing 97026 as time-based — the AMA codebook is the authority on the per-application status of this code. Billing time units against a per-application code risks overpayment recoupment.
• Failing to issue an ABN — treating a Medicare patient without an Advance Beneficiary Notice, then trying to collect after the denial. NCD 270.6 makes that denial predictable rather than a surprise.
• Unbundling incompatible codes — pairing 97026 with a code that NCCI edits restrict on the same date, without a valid modifier and supporting documentation
• Missing provider credentials — claims without the supervising clinician’s NPI and credentials are frequently flagged in Medicare audits of modality codes

The remittance advice is where the pattern shows up. Map the denial codes on your rejected 97026 claims back to the documentation behind each one, and you learn which note template needs fixing.

How Pabau keeps 97026 documentation and billing in one record

Practices that manage modality billing manually keep two records for one visit. The treatment note lives in one system and the claim is built in another. So the diagnosis, the treated area, and the credentials all get retyped, and that retyping is where denial risk accumulates.

Practice management software like Pabau removes that second entry. When a provider records an infrared application, the entry links straight to the billing record for that visit.

Pabau’s claims management software carries the ICD-10-CM diagnosis, the treated area, and the supervising clinician’s credentials onto the claim. Nobody rebuilds the note from memory at month end.

The outcome is a 97026 claim that already carries the evidence a payer asks for. Practices also see which modality claims are denied and why, so the fix lands in the note template instead of the appeals queue.

Reduce modality code denials with integrated billing

Pabau connects clinical documentation and claims management in one workflow. Document infrared therapy, assign billing codes, and submit clean claims without switching between systems.

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Conclusion

Infrared therapy is a small line on a claim with a lot of policy attached to it. NCD 270.6 settles the Medicare question before any documentation argument starts, which makes the ABN conversation part of booking rather than part of collections.

Where a commercial or workers’ compensation payer does cover it, documentation decides the claim. Capture the diagnosis, the treated area, the duration, and the supervising clinician while the patient is still in the room. To see how that record flows straight into the claim, book a demo.

Continue your research

Need to know why a 97026 claim came back? Denial management in healthcare explains how to build a systematic denial review and appeal workflow.

Comparing clearinghouse options for your practice? Medical claims clearinghouse guide covers how clearinghouses route and validate claims before they reach payers.

Want the ground rules for modality billing? Medical billing compliance sets out the documentation and audit standards behind clean submissions.

Checking benefits before the first session? Insurance eligibility verification shows how to confirm coverage and prior authorization at intake.

Looking at the whole payment cycle? Revenue cycle management traces a claim from booking through to reconciled payment.

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