The selection of the correct CPT® code is determined by three key factors from the case description: the type of examination, the age of the deceased, and the extent of the necropsy. The pathologist performed a "gross and microscopic" examination, eliminating codes for gross examination only (88012, 88014). The deceased was a "3-day-old," which is classified as a newborn. The necropsy included the brain. CPT® code 88029 accurately represents a gross and microscopic necropsy performed on a stillborn or newborn, which includes the brain.

A. 88028: This code is for an infant, not a newborn. A more specific code exists for a newborn, making 88029 the correct choice.

B. 88012: This code describes a gross examination only and is for an infant. The scenario specifies a gross and microscopic examination on a newborn.

D. 88014: This code describes a gross examination only. The scenario explicitly states that both a gross and microscopic examination were performed.

1. American Medical Association (AMA). (2023). CPT® 2024 Professional Edition.

Section: Pathology and Laboratory / Anatomic Pathology / Postmortem Examination.

Page/Code: CPT® code descriptors for 88028 and 88029. The manual distinguishes between "infant" (88028) and "stillborn or newborn" (88029) for gross and microscopic necropsies that include the brain. This distinction is critical for correct code selection.

2. AAPC. (2023). 2024 CPC Exam Study Guide.

Chapter: Pathology and Laboratory.

Section: Anatomic Pathology. The guide explains that code selection for necropsy (autopsy) is based on the extent of the examination (gross vs. gross and microscopic) and the specifics of the case

such as the age (e.g.

newborn

infant) and whether the central nervous system (CNS) is included. This reinforces the principle of choosing the most specific code available.