CPT® Code 88028

1. Indications

The necropsy (autopsy) procedure is indicated for the following conditions:

• Infant Death Investigation A necropsy is performed to determine the cause of death in infants aged 1 to 12 months.
• Newborn Examination This procedure is also applicable for newborns (birth to 1 month) and stillborns (fetuses with a gestational age of 20 weeks or more) to investigate potential causes of death.

2. Procedure

The necropsy procedure involves several detailed steps to ensure a comprehensive examination of the infant's body.

• Step 1: External Examination The procedure begins with a thorough external examination of the infant's body. This includes taking full body and facial photographs, if appropriate, to document any visible abnormalities. The body is assessed for overall condition, and specific features such as the shape of the chest and abdomen are noted. Radiographic examinations may be performed to identify any new or healing bone fractures, skeletal dysplasia, metaphysitis, and cerebral calcifications, as well as to estimate bone maturation at ossification centers.
• Step 2: Measurement and Weighing The infant's body is weighed and measured, with specific measurements taken from crown to heel, crown to rump, head circumference, and foot length. These measurements are crucial for understanding the growth and development of the infant.
• Step 3: Head Examination A detailed examination of the head is conducted, looking for signs of abrasions, cephalohematoma, caput succedaneum, bulging fontanelles, and the condition of the sutures. This step is vital for identifying any trauma or abnormalities that may have contributed to the infant's death.
• Step 4: Facial and Skin Assessment The facial features are carefully noted, and the skin is examined for any abnormalities or lesions that may provide insight into the infant's health status prior to death.
• Step 5: Abdominal Examination The shape and size of the abdomen are assessed, with particular attention given to the presence of conditions such as omphalocele or gastroschisis, which can indicate congenital anomalies.
• Step 6: Examination of Cord, Placenta, and Membranes If the umbilical cord, placenta, and membranes are still attached, they are examined for signs of umbilical hypercoiling or knots, chorioamnionitis, and infarction, which can provide critical information regarding the pregnancy and delivery.
• Step 7: Genitalia and Anus Examination The genitalia are examined to determine the infant's gender, and the patency of the anus, vagina, and urethra is assessed to rule out any congenital defects.
• Step 8: Back and Spine Examination The back and spine are examined for neural tube defects, pigmented lesions, and hair tufts, which can indicate underlying genetic or developmental issues.
• Step 9: Gross Examination of Internal Organs A gross examination of the internal organs is performed using techniques similar to those described in related CPT codes. This step involves a thorough visual inspection of all major organs to identify any abnormalities.
• Step 10: Microscopic Examination Following the gross examination, a microscopic examination is conducted. Fluid and tissue specimens removed during the autopsy are placed onto slides for microscopic review. These specimens may also be cultured for pathogens and tested for genetic diseases, metabolic disorders, or the presence of drugs or chemicals.
• Step 11: Closure of the Body Upon completion of the autopsy, the body cavity is lined with an appropriate material, the internal organs are sealed into a plastic bag and returned to the body, and the abdomen and chest flaps are re-approximated and closed to ensure the integrity of the body.

3. Post-Procedure

After the necropsy is completed, the body is prepared for any necessary arrangements as per the family's wishes. The findings from the necropsy are documented in a detailed report, which may be used for further investigation or to provide closure to the family regarding the cause of death. It is essential that all specimens collected during the procedure are handled according to established protocols to ensure accurate results and maintain the integrity of the investigation.