2025 CPT code 88016

Gross examination of a macerated stillborn.

Follow CPT guidelines for anatomic pathology procedures and necropsy/autopsy services. Modifier 90 should be added if the gross examination is performed using outside laboratory services.

Modifier 90 (Reference Laboratory) is applicable if the service is performed by an outside laboratory.Other modifiers might be applicable depending on the specific circumstances.

Medical necessity is established when a gross examination is clinically appropriate and sufficient to determine the cause of death or when more extensive testing is unavailable or deemed inappropriate. The procedure should be documented within the context of the clinical situation.

The physician performs the visual examination of the macerated stillborn, documenting findings related to size, color, and consistency of the tissues.

IMPORTANT If the stillborn is not macerated or if a more extensive examination is performed (including the brain), other codes within the 88000-88099 range might be more appropriate.Code 88099 (Unlisted Necropsy) can be used for procedures not specifically listed in this range.

In simple words: The doctor examines a stillborn baby whose skin is broken down and softened.The doctor looks at the baby's body without using a microscope to see what might have caused its death. This is done if other tests aren't needed or possible.

This CPT code encompasses the physician's services for a gross examination of a macerated stillborn.The examination involves a visual macroscopic inspection of the stillborn without the use of a microscope, documenting the size, color, and consistency of the tissues.This procedure is typically performed when microscopic examination and laboratory testing are deemed unnecessary or unavailable to determine the cause of death.

Example 1: A stillborn infant is delivered, and the skin shows significant maceration.The physician performs a gross examination to document findings for the medical record and death certificate, without further testing deemed necessary., A macerated stillborn is received in a small rural clinic with limited laboratory resources. A gross examination is performed as the most feasible method to evaluate the cause of death., Following a stillbirth at home, a gross examination is carried out by the physician to determine possible causes of fetal demise, given that the family is against further invasive investigations.

Detailed documentation should include the patient's medical history, the circumstances surrounding the stillbirth, a description of the maceration, the findings of the gross examination, and any other relevant clinical observations.

** This code is specific to the physician's service for gross examination; additional charges may apply for services such as tissue handling or processing by a laboratory.

  • Revenue Code: P5E (AMBULATORY PROCEDURES - OTHER)
  • RVU: Information not available in source.Refer to the CMS Physician Fee Schedule for current RVU values.
  • Global Days : Not applicable. This is a single-procedure code.
  • Payment Status: Active
  • Modifier TC rule: Technical component (TC) modifier is not applicable to this code as it represents physician services only.
  • Fee Schedule : Information not available in source.Refer to historical CPT fee schedules for historical information.
  • Specialties:Obstetrics, Pathology, Forensic Pathology
  • Place of Service:Office, Hospital, Birthing Center
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