Autopsy Pathology

NAME OF PROCEDURE

Autopsy

CPT CODE

  • 88205:  Autopsy gross and microscopic with CNS
  • 88027:  Autopsy gross and microscopic with brain and spinal cord
  • 88014:  Autopsy on stillborn/ newborn with CNS evaluation

APPLIES TO

Autopsy Services

SYNONYMS

Necropsy; Postmortem Examination

SPECIAL INSTRUCTIONS

Southeastern Pathology Associates (SEPA) offers a full range of autopsy services.  If the facilities are adequate these may be performed at hospital mortuaries or funeral homes.  In the absence of adequate autopsy facilities, autopsies will be performed in the mortuary of the Southeast Georgia Health System, Brunswick Campus.

The following are guidelines to underscore when an autopsy may be appropriate:

  • Deaths in which the cause of death or a major diagnosis is not known on clinical grounds
  • Deaths in which an autopsy may help explain unanticipated medical complications to the physician.
  • Unexplained death occurring during or shortly after medical diagnostic or therapeutic procedure
  • Death suspected to have results from high risk contagious diseases
  • All obstetric or pediatric deaths.
  • Deaths of patients who have participated in clinical trials (protocols) approved by the hospital institutional board.
  • Deaths in which it is believed that the autopsy would disclose a known or suspected illness which may have a bearing on survivors or recipients of transplanted organs.
  • Deaths known or suspected to have resulted from environmental or occupational hazards.
  • Neonatal death due to congenital malformations.

PROCEDURE

To setup an autopsy the following procedures must be undertaken:

  1. Contact:
    • P. Godbey, Medical Director @ 912-261-2669 or 
    • Ken Fisher, Operations Manager @ 912-261-2669
  2.  A complete signed and witnessed <Authority For Autopsy Form> granting permission to perform an autopsy must be provided to Southeastern Pathology Associates.
  3. A signed <Hospital Autopsy Permit> will also be accepted.
  4. The body has to be clearly labeled as to name and age of the deceased.  If local facilities are not available, arrangements must be made with the funeral home or hospital to transport the body to Southeast Georgia Health System by the time designated for the autopsy examination to commence.  The pathologist will liaise with the Security of South Georgia Health Systems to accept the body.  When the autopsy is complete the designated funeral home will be called to remove the body from the mortuary.  Transportation costs are the responsibility of the referring hospital or family.
  5. A hospital Medical Record or good copies of other records, as may be available, should be provided to the pathologist performing the autopsy and must accompany the body in a clearly marked, sealed envelope.
  6. If tissues are needed for submission to additional agencies (asbestos/ medicolegal related autopsies) clearly indicate tissues required and provide the name and address of the person to whom the tissues should be sent.
  7. Hospital autopsies are usually charged directly to the hospital according to the contractual agreement with Southeastern Pathology Associates.
  8. Private autopsies will be charged directly to the family representative.  The private autopsy charge covers all professional fees, cost of supplies, autopsy assistant, slide preparation, disposables, and mortuary clean-up.

TURN-AROUND-TIME

  1. An autopsy takes approximately 6 hours to perform.
  2. A provisional report will be available within 48 hours.
  3. A completed report will be available within 90 days.

SPECIMEN

  1. Body to be stored in the morgue.
  2. Containers to be provided by the Pathologist.

REQUEST FORM

The signed <Authority for Autopsy Form> (autopsy permit) must be provided at the time of the autopsy.  When permission for an autopsy has been obtained, complete the autopsy permit which includes the signatures of the person legally responsible for the body of the deceased and two witnesses.

NOTE:

An autopsy will not be performed until the pathologist has a properly signed autopsy permit and pertinent medical records. A valid permit must contain the signature of the highest ranking survivor in the next-of-kin lineage which is listed as follows in decreasing order of responsibility:

For Adults:

  1. Spouse
  2. Children of legal age
  3. Parent Sibling of legal age
  4. Grandchildren of legal age
  5. Guardian of the person of the decedent at the time of his/ her death (other than a guardian as litem)
  6. Any other person accepting and authorized or under obligation to dispose of the body.

For minor children:

  1. Both parents
  2. One parent in the absence of the other if no contrary indications of the absent parent are known
  3. Custodial parent in divorce or separation
  4. Noncustodial parent in absence of custodial parent and in absence of known contrary indication of custodial parent
  5. The legal guardian, in the absence of parents
  6. Any other person accepting and authorizing or under obligation to dispose of the body

Consent may be given in the absence of actual notice of contrary indications by the decedent or actual notice of opposition by a prior class.  If the person legally responsible cannot sign the autopsy permit:

  • A telephone call is acceptable if the call is witnessed by two (2) hospital representatives (e.g. physician and/ or nurse), and both sign the permit as witnesses.

If any restrictions or limitations have been placed on the postmortem examination, these must be noted in writing on the autopsy permit.  If there are no restrictions, write <NONE> in the appropriate area.  In hospital cases it is the responsibility of the physician to obtain permission for the autopsy from the next-of-kin.  In all cases, except Medical Examiner’s cases, it is the responsibility of the private physician to complete the death certificate.

CAUSES FOR REJECTION

Inadequate clinical data, improper or incomplete permit, at the discretion of the pathologist.

LIMITATIONS

The final diagnosis in an autopsy is highly dependent on the clinical data provided, definitive diagnostic comment(s) may be limited in cases where this is not available or where advanced decomposition has been identified.