CPT® Code 88012

1. Indications

The necropsy (autopsy) procedure described by CPT® Code 88012 is indicated for the following conditions:

• Infant Mortality - To investigate the cause of death in infants aged 1-12 months.
• Newborn Examination - To perform a thorough examination on newborns (birth to 1 month) who have died.
• Stillbirth Assessment - To evaluate stillborn infants (in utero death of a fetus with gestational age of 20 weeks or more).

2. Procedure

The procedure for conducting a necropsy under CPT® Code 88012 involves several detailed steps to ensure a comprehensive examination of the infant's body.

• Step 1: External Examination - The necropsy begins with a thorough external examination of the infant's body. This includes taking full body and facial photographs to document any visible abnormalities. The body is weighed and measured, including measurements from crown to heel, crown to rump, head circumference, and foot length. The head is carefully examined for signs of trauma, such as abrasions, cephalohematoma, caput succedaneum, bulging fontanelles, and the condition of the sutures.
• Step 2: Radiographic Examination - Radiographic imaging may be performed to identify any new or healing bone fractures, skeletal dysplasia, metaphysitis, and cerebral calcifications. This imaging helps in estimating bone maturation at ossification centers, providing additional insights into the infant's condition.
• Step 3: Detailed Body Examination - The examination continues with a detailed assessment of the chest and abdomen. The shape of the chest is noted, along with any presence of crepitus. The abdomen is examined for shape and size, and any abnormalities such as omphalocele or gastroschisis are documented. If the umbilical cord, placenta, and membranes are still attached, they are examined for conditions like umbilical hypercoiling, knots, chorioamnionitis, and infarction.
• Step 4: Genital and Spine Examination - The genitalia are examined to determine the infant's gender and to check the patency of the anus, vagina, and urethra. The back and spine are also assessed for neural tube defects, pigmented lesions, and hair tufts, which may indicate underlying conditions.
• Step 5: Internal Organ Examination - Following the external examination, the internal organs are examined using techniques similar to those described in CPT® Code 88000. This includes a focused examination of the brain, as detailed in CPT® Code 88005, to identify any potential abnormalities or causes of death.

3. Post-Procedure

After the necropsy is completed, the findings are documented in a detailed report, which may be used for further investigation or to provide closure to the family. The examination results can also contribute to medical research and understanding of infant mortality. It is important to handle the remains with care and respect, ensuring that any necessary arrangements for the infant's remains are made in accordance with the family's wishes and local regulations. The expected recovery from the procedure is immediate, as it is a post-mortem examination, and no physical recovery is required for the infant.