CPT® Code 88014

1. Indications

The necropsy (autopsy) described by CPT® Code 88014 is indicated for the examination of stillborn infants or newborns who have died shortly after birth. The specific indications for performing this procedure include:

• Stillborn Infants - Examination of fetuses that have died in utero with a gestational age of 20 weeks or more.
• Newborns - Assessment of infants who have died within the first month of life.
• Infants Aged 1-12 Months - Evaluation of infants within this age range when a gross examination is warranted.

2. Procedure

The procedure for conducting a necropsy under CPT® Code 88014 involves several detailed steps to ensure a comprehensive examination of the stillborn or newborn. The procedural steps include:

• Step 1: External Examination - The first step involves a thorough external examination of the body. This includes taking full body and facial photographs, if appropriate, to document the condition of the infant or stillborn. The body is weighed and measured, with specific attention to dimensions such as crown to heel, crown to rump, head circumference, and foot length.
• Step 2: Head Examination - The head is examined for various conditions, including abrasions, cephalohematoma, caput succedaneum, bulging fontanelles, and the status of the sutures, which may be separated or overriding.
• Step 3: Facial and Skin Assessment - Facial features are noted, and the skin is examined for integrity and any abnormalities. The shape of the chest is assessed, along with the presence of crepitus, while the abdomen is evaluated for shape, size, and any signs of omphalocele or gastroschisis.
• Step 4: Examination of Attached Structures - If the umbilical cord, placenta, and membranes are still attached, they are examined for conditions such as umbilical hypercoiling, knots, chorioamnionitis, and infarction.
• Step 5: Genitalia and Anus Examination - The genitalia are examined to determine gender, and the patency of the anus, vagina, and urethra is assessed to ensure there are no obstructions.
• Step 6: Back and Spine Assessment - The back and spine are examined for neural tube defects, pigmented lesions, and hair tufts, which may indicate underlying conditions.
• Step 7: Internal Organ Examination - Following the external examination, internal organs are examined using techniques similar to those described in CPT® Code 88000. This includes a detailed examination of the brain as outlined in CPT® Code 88005, ensuring that all relevant findings are documented.

3. Post-Procedure

After the necropsy is completed, the findings are documented in a detailed report, which may be used for further investigation or legal purposes. The expected recovery from the procedure is not applicable in the traditional sense, as the necropsy is performed on deceased individuals. However, it is important to handle the remains with care and respect, ensuring that all examinations are conducted in a manner that honors the dignity of the deceased. Any additional considerations may include the need for further testing or analysis based on the findings of the gross examination, as well as communication with the family regarding the results of the necropsy.