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CPT®
0196T

CPT® Code 0196T
Deleted

Code deleted, see 22899

Official Description

L4-L5 interspace (List separately in addition to code for primary procedure)

© Copyright 2025 American Medical Association. All rights reserved.

Common Language Description

The CPT® Code 0196T refers to a specific procedure involving the L4-L5 interspace, which is a critical area in the lumbar spine. This code is utilized in conjunction with a primary procedure, specifically when lumbar arthrodesis is performed. Lumbar arthrodesis, commonly known as spinal fusion, is a surgical technique aimed at stabilizing the spine by fusing two or more vertebrae together. In this case, the procedure employs a pre-sacral interbody technique, which is also known as transsacral or paracoccygeal approach. This minimally invasive method allows access to the anterior portion of the disc space through a small incision made near the coccyx, facilitating the preparation of the interspace for fusion. The procedure involves the removal of intervertebral disc material and cartilage from the end plates of the adjacent vertebrae, followed by the placement of bone graft material to achieve fusion. The use of fluoroscopic guidance during the procedure enhances precision and safety. It is important to note that this code is reported separately in addition to the primary procedure code when the L4-5 interspace is involved in the surgical intervention.

© Copyright 2025 Coding Ahead. All rights reserved.

1. Indications

The procedure associated with CPT® Code 0196T is indicated for patients experiencing conditions that necessitate lumbar arthrodesis at the L4-L5 interspace. These indications may include:

  • Degenerative Disc Disease - A condition where the intervertebral discs lose hydration and elasticity, leading to pain and reduced mobility.
  • Spinal Instability - Situations where the vertebrae are unable to maintain their normal position, potentially causing pain and neurological symptoms.
  • Herniated Discs - Occurs when the inner gel-like core of the disc protrudes through the outer layer, pressing on nearby nerves and causing pain.
  • Spinal Stenosis - A narrowing of the spinal canal that can lead to pressure on the spinal cord and nerves, resulting in pain and weakness.

2. Procedure

The procedure for CPT® Code 0196T involves several critical steps to ensure successful lumbar arthrodesis at the L4-L5 interspace. The steps are as follows:

  • Step 1: Patient Positioning - The patient is positioned in a prone manner on the operating table to provide optimal access to the lumbar region. This positioning is crucial for the subsequent steps of the procedure.
  • Step 2: Incision and Access - A small incision is made at the level of the coccyx, slightly lateral to the midline. This incision allows for the insertion of instruments needed to access the interspace.
  • Step 3: Trocar Advancement - A trocar is carefully advanced anterior to the sacrum under fluoroscopic guidance. This imaging technique ensures accurate placement and minimizes the risk of injury to surrounding structures.
  • Step 4: Creation of Presacral Channel - A small presacral channel is created within the disc space, facilitating access to the intervertebral area that requires intervention.
  • Step 5: Disc Preparation - The two adjacent vertebral bodies are distracted, and the intervertebral disc material is meticulously removed. Additionally, cartilage from the end plates of the adjacent vertebrae is also excised to prepare for the fusion.
  • Step 6: Graft Acquisition - Bone graft material, either from a donor (allograft) or the patient (autograft), is obtained to be used in the fusion process.
  • Step 7: Spinal Fusion - The final step involves packing the harvested bone graft material into the prepared disc space, thereby facilitating the fusion of the L4-L5 vertebrae.

3. Post-Procedure

After the completion of the procedure associated with CPT® Code 0196T, patients typically undergo a recovery period that may involve monitoring for any complications. Post-procedure care may include pain management, physical therapy, and follow-up appointments to assess the healing process. Patients are often advised to avoid strenuous activities and follow specific rehabilitation protocols to ensure optimal recovery and successful fusion of the vertebrae. The expected recovery time can vary based on individual patient factors and the extent of the surgical intervention.
Short Descr PRESCRL FUSE W/O INSTR L4/L5
Medium Descr ARTHRODESIS PRESACRAL INTRBDY W/O INSTRUM L4/L5
Long Descr L4-L5 interspace (List separately in addition to code for primary procedure)
Status Code Carriers Price the Code
Global Days XXX - Global Concept Does Not Apply
PC/TC Indicator (26, TC) 0 - Physician Service Code
Multiple Procedures (51) 0 - No payment adjustment rules for multiple procedures apply.
Bilateral Surgery (50) 0 - 150% payment adjustment for bilateral procedures does NOT apply.
Physician Supervisions 09 - Concept does not apply.
Assistant Surgeon (80, 82) 0 - Payment restriction for assistants at surgery applies to this procedure...
Co-Surgeons (62) 0 - Co-surgeons not permitted for this procedure.
Team Surgery (66) 0 - Team surgeons not permitted for this procedure.
Diagnostic Imaging Family 99 - Concept Does Not Apply
APC Status Indicator Inpatient Procedures, not paid under OPPS
Type of Service (TOS) 2 - Surgery
Berenson-Eggers TOS (BETOS) P1G - Major procedure - Other
MUE Not applicable/unspecified.
CCS Clinical Classification 158 - Spinal fusion
Date
Action
Notes
2019-01-01 Deleted Code deleted, see 22899
2017-01-01 Changed Guidelines changed.
2013-01-01 Changed Description changed. Guideline information changed. Also, short and medium descriptors changed per AMA 2013 corrections document.
2009-01-01 Added -
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