CurrentPriority HealthPolicy N/A

Always / Sometimes Therapy — Outpatient PT/OT/SLP billing and coding guidance

Defines billing and coding requirements for outpatient physical, occupational, and speech-language therapy services, distinguishing 'always therapy' (therapist under certified plan of care) from 'sometimes therapy' (qualified health professionals outside a certified plan of care). Intended for providers and billing staff submitting claims to Priority Health.

Policy Summary

PayerPriority Health

PolicyAlways / Sometimes Therapy — Outpatient PT/OT/SLP billing and coding guidance

Policy CodePolicy N/A

Change TypeCoding & disclaimer updates (2025–2026)

Effective DateDec 26, 2024

Next Review DateN/A

Key ActionReport always-therapy codes with the appropriate GN/GO/GP modifier and use the correct revenue code series (042x PT, 043x OT, 044x SLP) when billing; ensure full documentation to support claims.

SourceLink

POLICY UPDATE CHANGES

Added 'Disclaimer' section.

Added revenue code information under 'Coding specifics'.

Removed 'Applies to' section.

Updated 'Disclaimer' section.

~120CPT/HCPCS codes listed (approximate)

3G-modifier categories required

3Therapy disciplines referenced

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Policy Snapshot

This policy defines billing and coding requirements for outpatient physical, occupational, and speech-language therapy services, distinguishing "always therapy" (therapy provided by a qualified therapist under a certified therapy plan of care) from "sometimes therapy" (services provided by a qualified health professional other than a therapist, outside a certified therapy plan of care). It is intended for providers and billing staff submitting claims to Priority Health to ensure accurate reporting of CPT/HCPCS and revenue codes, modifiers, and plan-of-care requirements.

Subject: Outpatient therapy coding and billing (Always vs Sometimes therapy). Status: CURRENT. Effective date: 2024-12-26; Last review: 2026-03-18.

Policy facts

Effective Date2024-12-26

Last Review2026-03-18

Next Review DateN/A

Policy CodeN/A

Key Action summaryDefines billing and coding requirements for outpatient PT, OT, and SLP services, distinguishing 'always therapy' (therapist under certified plan of care) from 'sometimes therapy' (qualified health professionals outside a certified plan of care) and requiring appropriate G-modifiers and revenue codes when billing.

Clinical and Administrative Background

This policy provides administrative and clinical context for outpatient rehabilitative services, outlining when therapy codes must be billed under a certified therapy plan of care, and clarifying that documentation, coding accuracy, and medical necessity are required for payment. It distinguishes the definitions of Always therapy and Sometimes therapy and explains that when sometimes-therapy codes are delivered by a therapist they must follow always-therapy billing rules.

The document references external resources and guidance, including CMS coding guidance and a CMS-related MLN article for outpatient physical and occupational therapy billing and coding. The policy reiterates that proper documentation and coding are necessary and that payment integrity reviews may be performed; failure to follow guidelines can result in claim rejection, denial, or recoupment.

Policy references the CMS annual therapy update: yearly changes to the "always therapy" code set are tracked in the CMS Annual Therapy Update (see column 5), and providers should consult that source for annual code updates.

Medical Necessity / Coverage Rules

Code Lists and Coding Specifics

Always therapy — GN modifier required (speech-language pathology evaluations)CPTCovered

92521	Evaluation of speech fluency
92522	Evaluation of speech sound production
92523	Evaluation of speech sound production; with evaluation of language comprehension and expression
92524	Behavioral and qualitative analysis of voice and resonance
92597	Evaluation for use and/or fitting of voice prosthetic device to supplement oral speech
92607	Evaluation for prescription for speech-generating AAC device, face-to-face; first hour

Always therapy — GO modifier required (occupational therapy evaluations)CPTCovered

97165	OT evaluation, low complexity
97166	OT evaluation, moderate complexity
97167	OT evaluation, high complexity
97168	Re-evaluation of occupational therapy established plan of care

Always therapy — GP modifier required (physical therapy evaluations)CPTCovered

97161	PT evaluation, low complexity
97162	PT evaluation, moderate complexity
97163	PT evaluation, high complexity
97164	Re-evaluation of physical therapy established plan of care

Always therapy — GN/GO/GP required (therapy procedures and modalities)mixedCovered

92507	Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual
92508	Treatment...; group, 2 or more
92526	Treatment of swallowing dysfunction/oral function for feeding
92605	Eval for prescription of non-speech-generating AAC device; first hour
92606	Therapeutic services for use of non-speech-generating device; programming/modification
92608	Eval for prescription for speech-generating AAC device; each additional 30 minutes
92609	Therapeutic services for use of speech-generating device; programming/modification
92618	Evaluation for prescription of non-speech-generating AAC device; each additional 30 minutes
96125	Standardized cognitive performance testing, per hour
97010	Hot or cold packs

1–10 of 43

1/5

Sometimes therapy codes (qualified health professionals or non-therapist services)mixed

90901	Biofeedback training by any modality
90911	Biofeedback training, perineal muscles, including EMG/manometry
90912	Biofeedback training, perineal muscles; initial 15 minutes by qualified professional
90913	Biofeedback training, perineal muscles; additional 15 minutes
92520	Laryngeal function studies
92610	Evaluation of oral and pharyngeal swallowing function
92611	Motion fluoroscopic evaluation of swallowing
92612	Flexible endoscopic evaluation of swallowing (FEES)
92614	Flexible endoscopic evaluation, laryngeal sensory testing
92616	Flexible endoscopic eval of swallowing and laryngeal sensory testing

1–10 of 31

1/4

ModifiersModifier

GN	Services performed under an outpatient speech pathology plan of care
GO	Services performed under an outpatient occupational therapy plan of care
GP	Services delivered under an outpatient physical therapy plan of care
XP	Separate practitioner, distinct service

Revenue code guidanceRevenue

042x	Revenue codes series for physical therapy
043x	Revenue codes series for occupational therapy
044x	Revenue codes series for speech therapy

Coding/billing thresholds

Electrical stimulation wound care requirementG0281 and G0329: for chronic Stage III and Stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care as part of a therapy plan of care.

Billing, Documentation, and Authorization Requirements

Billing Rule

Modifier usage

Always therapy codes must be reported with the appropriate therapy modifier (GN, GO or GP). No claim line should contain more than one occurrence of the listed G modifiers.

Billing Rule

Revenue code reporting

Use correct revenue code series when billing therapy services: 042x for physical therapy, 043x for occupational therapy, 044x for speech therapy.

042x
043x
044x

Defined Terms

Definitions

Always therapyTherapy services provided by a qualified therapist under a certified therapy plan of care.

Sometimes therapyTherapy services provided by a Qualified Health Professional other than a therapist, outside a certified therapy plan of care.

Operational Coding and Revenue Guidance

Revenue code series are mapped to therapy disciplines for billing accuracy: use 042x for physical therapy, 043x for occupational therapy, and 044x for speech therapy. This mapping was added to the policy under "Coding specifics" in the March 18, 2026 update.

Revenue code guidanceRevenue

042x	Revenue codes series for physical therapy
043x	Revenue codes series for occupational therapy
044x	Revenue codes series for speech therapy

Policy Update Changes

2025-02-14added

Added 'Disclaimer' section; inserted disclaimer text clarifying applicability of CMS/MDHHS guidance, billing responsibilities, and recoupment rights.

2026-03-18addedLatest

Added revenue code information under 'Coding specifics' (mapping revenue code series 042x for PT, 043x for OT, 044x for SLP); also removed the 'Applies to' section and updated the 'Disclaimer' section.