CPT® Code 88016

A necropsy, commonly referred to as an autopsy, is a thorough examination performed on deceased individuals, specifically infants and stillborns, to determine the cause of death and assess any underlying conditions. The procedure described by CPT® Code 88016 pertains to a gross examination of a macerated stillborn, which is defined as a fetus that has died in utero with a gestational age of 20 weeks or more. During this examination, a variety of assessments are conducted to gather critical information about the infant's condition prior to death. This includes an external examination that may involve taking full body and facial photographs, as well as performing radiographic evaluations to identify any skeletal abnormalities or injuries. The examination process is comprehensive, encompassing measurements of the body, including weight and dimensions from crown to heel, crown to rump, head circumference, and foot length. The head is scrutinized for any signs of trauma or abnormalities, such as abrasions, cephalohematoma, and bulging fontanelles. Additionally, the examination extends to the facial features, skin integrity, and the shape of the chest and abdomen, noting any significant findings such as crepitus or congenital defects like omphalocele or gastroschisis. If the umbilical cord, placenta, and membranes are still attached, they are also examined for any pathological conditions. The genitalia are assessed to ascertain gender and the patency of the anal, vaginal, and urethral openings. The back and spine are evaluated for neural tube defects and other anomalies. Internal organs are examined using techniques similar to those outlined in CPT® Code 88000, with particular attention given to the brain, as detailed in CPT® Code 88005. It is important to note that the examination of a macerated stillborn is often limited due to the advanced decomposition of the body, which can hinder the ability to conduct a thorough assessment, particularly of the brain. Maceration, or aseptic autolysis, begins shortly after fetal death and is characterized by various physical changes, including skin sloughing, discoloration, and fluid accumulation, which further complicate the necropsy process.