In simple words: This code means the doctor thought about whether the patient needed rehabilitation services.

This Category II CPT code signifies that rehabilitation services have been considered for the patient.It's a supplemental tracking code used for performance measurement and quality improvement, not for reimbursement. This code does not have a relative value unit (RVU).

Example 1: A patient presents with a stroke. The physician documents consideration of rehabilitation services, including physical therapy and occupational therapy, to assess the patient's need for such services. Code 4079F is appended to reflect this consideration., A patient recovering from a hip fracture has a comprehensive assessment, and the physician documents that the patient’s condition does not require formal rehabilitation, thus 4079F would be used to reflect that consideration was given., A patient with multiple sclerosis is evaluated, and the physician documents a thorough assessment of their current functional status and need for rehabilitation, ultimately recommending specialized therapy. Code 4079F is appended to indicate this consideration.

Medical record should clearly document the evaluation process which included consideration of the patient's need for rehabilitation. The documentation should include the patient's history, physical examination findings, any diagnostic tests conducted, and the physician's rationale for the decision regarding rehabilitation services.

** Code 4079F is a supplemental tracking code for quality reporting purposes. It's not used for billing or reimbursement.It's important to note that this code alone doesn't indicate whether rehabilitation was or was not provided; it only notes that the decision about the need for such services was considered.