CPT® Code 88016

1. Indications

The necropsy (autopsy) procedure described by CPT® Code 88016 is indicated for the examination of macerated stillborns, specifically in cases where there is a need to determine the cause of death or assess any potential congenital anomalies. The following conditions may warrant this procedure:

• Stillbirth - The examination is performed on fetuses that have died in utero with a gestational age of 20 weeks or more.
• Assessment of Congenital Anomalies - The procedure is indicated when there is a suspicion of congenital defects or abnormalities that may have contributed to the stillbirth.
• Maternal Health Concerns - If there are maternal health issues that could impact fetal development or viability, a necropsy may be warranted to investigate potential links.
• Legal or Forensic Investigation - In cases where there may be legal implications surrounding the stillbirth, a necropsy can provide critical information.

2. Procedure

The procedure for conducting a necropsy on a macerated stillborn involves several detailed steps to ensure a comprehensive examination. Each step is crucial for gathering accurate information regarding the condition of the fetus at the time of death.

• Step 1: External Examination - The necropsy begins with a thorough external examination of the body. This includes taking full body and facial photographs to document the condition of the 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. The head is examined for any signs of trauma, including abrasions, cephalohematoma, and bulging fontanelles.
• Step 2: Radiographic Evaluation - A radiographic examination 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.
• Step 3: Detailed Physical Assessment - The chest shape is assessed, noting any presence of crepitus, while the abdomen is examined for shape and size, including any signs of omphalocele or gastroschisis. The umbilical cord, placenta, and membranes are also examined for conditions such as umbilical hypercoiling or knots, chorioamnionitis, and infarction.
• Step 4: Genital and Anal Examination - The genitalia are examined to determine the gender of the stillborn, and the patency of the anus, vagina, and urethra is assessed to ensure there are no obstructions or abnormalities.
• Step 5: Back and Spine Evaluation - The back and spine are examined for neural tube defects, pigmented lesions, and hair tufts, which may indicate underlying conditions.
• Step 6: Internal Organ Examination - Following the external assessment, internal organs are examined using techniques similar to those described in CPT® Code 88000. Special attention is given to the brain, as outlined in CPT® Code 88005, although examination may be limited due to decomposition.

3. Post-Procedure

Post-procedure care following a necropsy on a macerated stillborn typically involves the careful handling of the remains, ensuring that they are treated with dignity and respect. Due to the nature of the examination, the findings may be documented in a report that outlines the observations made during the necropsy. This report can be critical for medical records, legal purposes, or further investigation into the circumstances surrounding the stillbirth. Additionally, the family may be provided with information regarding the findings, if appropriate, to help them understand the circumstances of their loss. It is important to note that the examination of a macerated stillborn may yield limited results due to the advanced state of decomposition, which can affect the overall findings and conclusions drawn from the necropsy.