How To Use CPT Code 88036

CPT 88036 describes the postmortem examination procedure performed by a physician to examine one region of the body after death. This article will cover the description, official details, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, similar codes and billing examples.

1. What is CPT Code 88036?

CPT 88036 can be used to describe the postmortem examination procedure performed by a physician to examine one specific region of the body after death. This code is used when the physician performs a gross examination, microscopic examination, or both, to assess the region of interest. The examination may involve taking swabs, fluids, or thin sections of tissue for further analysis under a microscope.

2. Official Description

The official description of CPT code 88036 is: ‘Necropsy (autopsy), limited, gross and/or microscopic; regional.’

3. Procedure

1. The physician performs a gross examination of the region of interest, assessing what can be seen without the need for microscopic examination or lab testing.
2. If necessary, the physician may perform a microscopic examination by taking swabs, fluids, or thin sections of tissue from the region and examining them under a microscope.
3. The postmortem examination is performed to confirm or rule out a suspected cause of death. For example, in the case of a gunshot wound, the physician may examine the specific region of the body to determine which blood vessels or organs were affected by the bullet.

4. Qualifying circumstances

CPT 88036 is performed when there is a need to examine one specific region of the body after death. This examination is not limited to testing for a specific condition but can be performed to confirm or rule out a suspected cause of death. The physician performing the examination must complete all the technical steps required for the gross and/or microscopic examination of the region of interest.

5. When to use CPT code 88036

CPT code 88036 should be used when a physician performs a postmortem examination of one specific region of the body after death. This code is not used to represent additional testing but rather the physician’s service in examining the region of interest. It is important to note that CPT code 88036 should not be reported with other codes for testing performed by an outside laboratory.

6. Documentation requirements

To support a claim for CPT code 88036, the physician must document the following information:

• The reason for performing the postmortem examination and the suspected cause of death
• The specific region of the body examined
• The date and time of the examination
• Details of the gross and/or microscopic examination performed
• Any findings or observations made during the examination
• The physician’s signature

7. Billing guidelines

When billing for CPT code 88036, ensure that the examination is performed by a physician and is limited to one specific region of the body. It is important to note that this code represents the physician’s service and does not include additional testing performed by an outside laboratory. If additional testing is performed, modifier 90 may need to be appended to indicate that the testing was performed by a reference or outside laboratory.

8. Historical information

CPT code 88036 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates or changes to the code since its addition.

9. Examples

1. A physician performing a postmortem examination of the brain to assess the extent of damage caused by a traumatic injury.
2. A physician conducting a postmortem examination of the heart to determine the cause of death in a patient with a history of cardiac disease.
3. A physician performing a postmortem examination of the lungs to assess the presence of any underlying respiratory conditions.
4. A physician conducting a postmortem examination of the liver to investigate potential liver disease as a contributing factor to the patient’s death.
5. A physician performing a postmortem examination of the gastrointestinal tract to identify any abnormalities or diseases that may have led to the patient’s death.
6. A physician conducting a postmortem examination of the kidneys to assess their function and identify any potential renal diseases.
7. A physician performing a postmortem examination of the reproductive organs to investigate any potential reproductive system-related causes of death.
8. A physician conducting a postmortem examination of the musculoskeletal system to assess any injuries or conditions that may have contributed to the patient’s death.
9. A physician performing a postmortem examination of the nervous system to investigate any potential neurological causes of death.
10. A physician conducting a postmortem examination of the endocrine system to assess the function of various glands and identify any potential endocrine disorders.