Q: What is the correct code for epidural hematoma extending to various levels of the spine, for example T12-L2, or C1-2-3-4 with an epidural at level C2?

A: This question often leads to come confusion with what and how to code all the issues. What level do you code, what if there is an associated deficit? A spinal epidural with no deficit is coded at the most superior level at which it is found. In the case of the first example T12-L1 it would be coded under the T-spine codes. If the patient has a deficit it makes a difference in the “legal” coding in 2008. 640200.3 is where you would code the C2 epidural, C1 gets the fx code only, C3 through C4 fxs are each coded individually. The problem is that the descriptor for C – spine fractures reads “Fx with or without dislocation but no cord involvement (italics added) If you follow the rules strictly you should not code the C2 fx on p 104, but if there is no deficit you can”t code the C2 fx with the epidural code – you would have to pick between transient, incomplete and complete on that page to get to a fx code. We have fixed this in the next version of AIS, but in the meantime, following the letter of the law, you will lose one or the other finding (the C2 fx or the epidural).