Autopsy

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Permission for an autopsy and available patient medical records is obtained using SF523.
This form must be completed before admiting the body to the morgue.
(must . ..Manual of the Medical Department, Chapter 17-18 and NAVMEDCENPTSVAINST 5360.1 series should be consulted for details concerning the proper handling of deaths and related matters.
The Decedent Affairs Office is available for assistance at Ext.3-2617.

Test Code

Autopsy

Instructions

Preparing the body for Morgue Admission: Adult: Complete 3 Deceased Remains Tags, NAVMEDCEN 5360/3 (Rev. 8/95)by completely filling out the tags with the patient identification, Rank/Rate, SSN, Status, Date of Death, Time of Death, Clinic, Diagnosis, Providers name and providers/charge nurse signature on each tag. This information may be handwritten on each tag or a computer generated label containing the information may be applied to each tag to identify the remains. Attach one tag to the right wrist, one to the right great toe of the remains. (Always use universal Precautions in handling body).
The remains should come to the morgue placed in a body bag and a Deceased Remains Tag must be placed on the outside zipper of the body bag. A gurney sheet should be placed over the body and the body can then be transported to the morgue. The ward of clinic may borrow a covered gurney so it is not obvious to patients that a patient has passed.

Permission for an autopsy is obtained using SF523. The consent must be obtained by a physician, and this physician, plus at least one other staff member, must sign the form as witnesses. It is imperative that the family member be apprised of the nature of the autopsy (i.e., informed consent obtained) and their desire for any limitations of the autopsy be determined (i.e., head only, chest only, etc.). If such limitations are desired, they must be described in the appropriate place on the SF523. If no limitations are desired, then “NONE” must be written in that space. The form must have the appropriate date and time, and the relationship of the person signing the form to the deceased must be listed.

For Active Duty Deaths, permission for an autopsy can be granted by OAFME, the Office of the Armed Forces Medical Examiner (located in Rockville, MD; phone number-301-319-0000) or the member’s Commanding Officer. The NOK is typically not approached for permission to perform an autopsy in the case of active duty deaths.

For all deaths in which the manner is other than natural (homicides, suicides, accidents) and in all pediatric deaths, the Regional Armed Forces Medical Examiner should be contacted to discuss any potential medicolegal issues. Non-natural deaths which occur in NMCP fall under the jurisdiction of the Tidewater Office of the Chief Medical Examiner of the State of Virginia (TOCME). These cases must be released by the Medical Examiner prior to autopsy or other disposition of the body, either by contacting the OAFME, or by contacting the Virginia Medical Examiner directly at 683-8366.

Fetal Autopsies: As defined in the Code of Virginia (Section 32.1-249), fetal death means death prior to the complete expulsion or extraction from its mother of a product of human conception, regardless of the duration of pregnancy; death is indicated by the fact that after such expulsion or extraction the fetus does not breathe or show any other evidence of life such as beating of the heart, pulsation of the umbilical cord, or definite movement of voluntary muscles.

It is the policy of the laboratory that fetuses are to be handled in accordance with the wishes of the parents, and that the wishes of parents are determined prior to any invasive examination. Autopsies are frequently very useful as a means of delineating congenital defects and other problems, which may have resulted in an intrauterine fetal demise. An autopsy is also extremely helpful in order to document the absence of any discernible heritable anomalies and thereby allay parent’s fears. However, it must be remembered that an autopsy is an invasive procedure and as such, will not be performed without the express permission of the parents.

For fetuses greater than or equal to 20 weeks gestational age and/or 500 grams in weight:

If an autopsy is desired by the parents, a standard autopsy permit must be signed as described above. It is not necessary that both parents sign. The fetus and placenta should be transported to the morgue along with the autopsy permit and a copy of the inpatient chart.
If no autopsy is desired, no permit is submitted, and/or the fetus is less than 20 weeks/500 grams, the fetus will receive a gross (external) examination only, with anthropometric measurements made. The attending physician must place an order into CHCS or AHLTA requesting that surgical pathology be performed. This external examination will be reported in a surgical pathology report.
It is important to contact the Decedent Affairs office when a fetal death has occurred, so that they can assist with counseling parents on disposition options.
It will occasionally be the case that fetal tissue will only be recognized after examination in the laboratory. In these cases, the laboratory will contact the Decedent Affairs office, which will in turn then contact the parents to discuss disposition options.

Reject Criteria (Eg, hemolysis? Lipemia? Thaw/Other?)

IT MUST BE REMEMBERED THAT AN AUTOPSY WILL NOT BE PERFORMED UNLESS A VALID AUTOPSY PERMIT IS COMPLETED. IT IS THE RESPONSIBILITY OF THE ATTENDING PHYSICIAN TO ENSURE THAT THIS CONSENT HAS BEEN PROPERLY OBTAINED AND DOCUMENTED.

Setup Schedule

Scheduling (Except as directed by the Laboratory Director or duty pathologist): Routine autopsies are performed 5 days a week, Monday through Friday, during normal working hours. Generally, autopsies will not commence after 1400. Autopsies which will require performance at night or on weekends because of special circumstances may be arranged by contracting pathology during regular working hours or the duty pathologist in the evening or on weekends.

Limitations

Although it is recommended that a request for autopsy be made on every death, it is recognized that performing an autopsy on every death may not be possible. Deaths in which an autopsy should be especially encouraged are as follows:
-Deaths in which the cause is uncertain on clinical grounds or when there are unexplained medical complications.
-Cases in which autopsy may help allay concerns and provide reassurance to the family and/or public concerning the deaths.
-Deaths occurring during or following diagnostic or therapeutic procedures.
-Death of patients participating in clinical trials.
-Apparently natural deaths of sudden, unexpected or unexplained nature either waived by or not subject to a forensic medical jurisdiction such as: Persons dead on arrival at a hospital Deaths occurring within 24-hours of hospitalization.
-Deaths of patients apparently injured while hospitalized.
-All neonatal, pediatric, and obstetric deaths.
-Deaths arising from high-risk infections or contagious disease.
-Deaths involving transplant patients.
-Deaths suspected as due to environmental or occupational hazards/accidents.
-In Deaths Involving Radioactivity, the Radiation Safety Officer must be notified and NAVMEDCENPTSVA INST 6470.2C pertains. These cases are generally discouraged for autopsy due to risk to laboratory personnel.
-Cases involving suspected Creutzfeld-Jacob Disease (CJD) or other spongiform encephalopathies are typically limited to internal examination of the head only. Consultation should be sought with the Head, Autopsy Service at the earliest possible point so that adequate planning and preparation can occur.

The CPT Codes provided in this document are based on AMA guidelines and are for informational purposes only. CPT coding is the sole responsibility of the billing party. Please direct any questions regarding coding to the payor being billed. Any Profile/panel component may be ordered separately. Reflex tests are performed at an additional charge.