Q: Have the following finding on a patients MRI – “œsmall epidural hematoma from C7-T1 which is likely emanating from the compression fracture of T1″ ““ He does not have a C7 fracture. What would you code especially considering it involves the cervical and thoracic spine?

A: You should code the epidural at the highest level (C7) unless you have evidence of deficit at a lower level. You may not “double dip” and code the epidural again in the T-spine. Again, if there is no deficit, code 640200.3 for the epidural hematoma and 650430.2 for the compression fracture of T 1. If there would be a deficit with this injury then you would code the deficit at the level that it occurs.