2025 CPT code 88000

Necropsy (autopsy), gross examination only, without CNS.

This code represents physician services only. Use modifier 90 for outside laboratory services. Postmortem examination procedures not specified in 88000-88045 may be reported using 88099.

Modifier 90 is applicable when outside laboratory services are involved.

Medical necessity is established when the cause of death is unclear and requires further investigation or when requested by legal authorities (e.g., medical examiner).

The physician performs the gross examination of the body, excluding the central nervous system. This involves visual inspection without microscopic analysis.

IMPORTANT Codes 88005-88016 represent additional gross examination only autopsy coding options. Code 88099 is used for unlisted necropsy (autopsy) procedures not specified in codes 88000-88045.

In simple words: The doctor examines a dead body to see what caused death, without using a microscope. This examination doesn't include the brain or spinal cord.

This CPT code encompasses a physician's services for a gross examination of a body after death, excluding the central nervous system (CNS).The examination involves visual inspection without the use of a microscope.This procedure is not limited to specific disease investigations but may be performed when the cause of death is not sufficiently unclear to warrant microscopic examination.

Example 1: A patient dies unexpectedly at home, and the family requests a postmortem examination to determine the cause of death. The physician performs a gross examination only, without examining the CNS, documenting findings and preparing a report.This scenario involves a non-hospital setting and may be relevant for medico-legal purposes., In a hospital setting, a patient dies following a prolonged illness with a suspected but unclear cause of death. The physician conducts a gross examination, focusing on potential visible indicators related to their primary condition, without needing to examine the CNS due to a high degree of pre-mortem diagnostic clarity. A detailed report is prepared for the attending physician and the patient's records., A medical examiner requests a gross-only necropsy on a deceased individual where the cause of death is relatively clear from the initial scene assessment, and further CNS evaluation is deemed unnecessary. This scenario highlights medico-legal aspects of the procedure.

Detailed notes on the external examination of the body, including any visible signs of injury or disease.Internal examination findings (excluding CNS) should be documented with photographs, diagrams, and detailed descriptions of organ size, shape, color, and consistency.A comprehensive report summarizing findings should be completed.

** This code is only for the physician's service in performing the gross examination.Any additional microscopic examinations or laboratory tests should be reported with separate codes.

  • Revenue Code: P5E (AMBULATORY PROCEDURES - OTHER)
  • Payment Status: Active
  • Modifier TC rule: Not applicable.
  • Specialties:Forensic Pathology, Pathology
  • Place of Service:Office, Hospital, Morgue, Medical Examiner's Office
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