T CELLS AND THEIR RECEPTORS

Each T cell is also committed to a given antigen and recognizes it by one of two TCRs. They may have TCR2s composed of gamma (γ) and delta (δ) chains or TCR2s composed of another heterodimer of alpha (α) and beta (β) chains. These TCR2s are associated with a group of transmembrance proteins on the CD3 molecule, which takes the antigen recognition signal inside the cell. Signal transduction via the CD3 complex is regulated by a series of kinases, which are associated with the tails of the CD3–TCR complex and regulate phosphorylation. Defi ciencies or blocks in the T-cell signaling pathways either at the cell-surface complex or at the level of the kinases may result in various forms of immunodefi ciency. Two other important antigens present on TCR2 cells recognize histocompatibility antigens and will be discussed later. The genes for TCR chains are on different chromosomes with the β and α molecules on chromosome 7, while the α and δ are on chromosome 14. As seen in Figure 1.5, the four chains are made up of a variable region and a constant region similar to those observed with the immunoglobulins. The variable regions are also numerous and joined at D and J regions by RAG1 and RAG2. This permits a diversity of antigen recognition similar to that observed with immunoglobulin, but additional somatic mutation is not involved in T cells. These similarities have led to the concept that genes for antigen-specifi c T cells evolved in the same manner as immunoglobulin from a parent gene, and both are members of a superantigen family. 

The TCR complex recognizes small peptides presented to it by the MHC class I and II and depends on the type of T cell.  Helper T cells (CD4) recognize class II antigens while suppressor cytotoxic T cells (CD8) recognize class I antigens. Because of the rather low affi nity of the reactions, recognition of processed antigen alone is not suffi cient to activate T cells. Soluble interleukins are needed to complete the picture and are generated during the antigen processing.

The genetics of antibody production

The major mucosal immunoglobulin, IgA, consists of two basic units joined by a J chain. The addition of a secretion molecule prevents its digestion by enzymes present in mucosal and intestinal secretions. Thus, IgA2 is the major IgA molecule in secretions and is quite effective in neutralizing antigens that enter via these mucosal routes. IgA1, the main IgA molecule in serum, is, however, susceptible to inactivation by serum proteases and is thus less active for defense. Its function is unclear at present. 

Two other classes are worthy of note. IgD is synthesized by antigen-sensitive B cells and is involved in the activation of these cells by antigen. IgE is produced by plasma cells and binds to specifi c IgE receptors on most cells and basophiles. This molecule (see Chapter 9) plays an extremely important role in allergic reactions and expelling intestinal parasites, which is accomplished by increasing vascular permeability and inducing chemotactive factors following mast cell degranulation. 

Given this extraordinary ability to generate large numbers of antibody molecules, how does the immune system recognize all pathogens, including past, present, and future? This diversity is achieved by the way in which the genetics of antibody production is arranged (see Figure 1.3). The light and heavy chains are carried on different chromosomes. The heavy chain genes are carried on chromosome 14. These genes are broken up into coding systems called exons with intervening segments of silent segments called entrons. The exons represent the central region of the heavy chain and a large number of V regions. Between the V and D genes are two small sets of exons called the D and J. With each single B cell, one V gene is joined to one D and J in the chromosome. The product, the VH domain, is then joined at the level of RNA processing to Cu and the B cell makes an IgM molecule. By omitting the Cu gene and joining VHDJ to a Cλ an IgG molecule is produced. This enormous versatility allows the cell to make IgM, IgD, IgG, IgA, or IgE in sequence while using the same variable regions (see Figure 1.4). The heavy chain gene recombinations are controlled by two recombination activity genes called RAG1 and RAG2. If these genes are eliminated by “knock-out” techniques in mice, profound immunodefi ciency status occurs in these animals, characterized by absent mature B and T cells. 

Thus, the diversity of antigen binding is achieved by the large number of V genes available and their combination with different D and L genes to provide different antibodies. Furthermore, the inherited set of genes may be increased by somatic mutation during multiple divisions of lymphoid cells, thereby increasing the number of antibody specifi cities to 1014, which far exceeds the number of B cells (1010) in the body. 

Once a given B cell is preselected to produce a particular VH and VL domain, all the ensuing progeny of that B cell will produce the same VH or VL domain. The sequence of events is as follows: initially, the B cell produces intracellular antigen-specific IgM, which becomes bound to the cell surface. The B cell is now antigen responsive with exposure to a given antigen. The committed B cell begins producing a certain isotype or class of immunoglobulins and begins dividing, and all the progeny will produce the identical immunoglobulin molecules. These B cells will later mature into either plasma cells or long-term memory B cells.

ANTIGENS

Antigens are any substances that are capable, under appropriate conditions, of inducing the formation of antibodies and reacting specifi cally with the antibodies so produced. They react with both T-cell recognition receptors and with antibodies. These antigenic molecules may have several antigenic determinants, called epitopes, and each epitope can bind with a specifi c antibody. Thus, a single antigen can bind to many different antibodies with different binding sites.

Some low-molecular-weight molecules called haptens are unable to evoke an immune response but can react with existing antibodies. These molecules need to be coupled to a carrier molecule to be antigenic. 

For some molecules such as drugs, the molecule needs to be conjugated to a carrier. The carrier may be a host protein. The tertiary structure of the molecule as well as the amino acid sequence is important in determining antigenicity. Certain structures such as lipids and DNA are generally poor antigens. 

Most antigens are either thymusdependent or thymus-independent antigens. Thymus-dependent antigens require T-cell participation: Most proteins and foreign red cells are examples of these molecules. Thymus-independent antigens do not require T-cell participation for antibody production. Instead, they directly stimulate specifi c B lymphocytes by crosslinking antigen receptors on the surface of B cells. These molecules produce primarily IgM and IgG2 antibodies and do not stimulate long-lasting memory cells. Most bacterial polysaccharides (found in bacterial cell walls) fall into this category. Certain polysaccharides, such as LPS (lipopolysaccharide), not only induce specifi c B-cell activation but also can act as a polyclonal B-cell stimulant.

ANTIBODY

It consists of a four-chain structure divided into two identical heavy (H) chains with a molecular weight of 25 kDa. Each chain is composed of domains of 110 amino acids and is connected in a loop by a disulfide bond between two cysteine residues in the chain. 

The amino acid N-terminal domains of the heavy and light chains include the antigen-binding site. The amino acids of these variable domains vary between different antibody molecules and are thus known as the variable (V) regions. Most of these differences reside in the hypervariable areas of the molecule and are usually only six to ten amino acid residues in length. When the hypervariable regions in each chain come together along with the counterparts on the other pair of H and L chains, they form the antigen-binding site. This part of the molecule is unique to the molecule and is known as the idiotype determinant. In any individual, 106 to 107 different antibody molecules can be composed from 103 different heavy and light chains of the variable regions. The part of the molecule next to the V region is called the constant (C) region made up of one domain in the light chain (C1) and three or four in a heavy chain (CH). A Cl chain may consist of either two kappa (κ) or two lambda (λ) chains but never one of each. Of all the human antibody molecules, approximately 60%, are κ chains and 40% contain λ chains. Although there are no known differences in the functional properties of κ and λ chains, there are several different types of the CH domain. These differences are refl ected in determining the class (isotype) of the antibody and thereby the physiological function of a particular antibody molecule.

The IgM molecule is the oldest class of immunoglobulins, and it is a large molecule consisting of fi ve basic units held together by a J chain. The major role IgM plays is the intravascular neutralization of organisms, especially viruses. The reason for this important physiological role is that it contains fi ve complement-binding sites, resulting in excellent complement activation. This activation permits the segment removal of antigen–antibody complement complexes via complement receptors on phagocytic cells or complement-mediated lysis of the organism. However, in contrast to the IgG molecule, it has relatively low affi nity binding to the antigen in question. Second, because of its size, it does not usually penetrate into tissues. In contrast, IgG is a smaller molecule that penetrates easily into tissues. There are four major classes of IgG: IgG1 and IgG3 activate complement effi ciently and clear most protein antigens, including the removal of microorganisms by phagocytic cells. 

In contrast, IgG2 and IgG4 react mostly with carbohydrate antigens and are relatively poor opsonins. This is the only molecule that crosses the placenta to provide immune protection to the neonate.

Basic Components of the Immune System

It is generally believed that the immune system evolved as the host’s defense against infectious agents, and it is well known that patients with deficiencies in the immune system generally succumb to these infectious diseases

An immune response may be conveniently divided into two parts:

(1) a specifi c response to a given antigen and

(2) a more nonspecifi c augmentation to that response.

An important feature of the specific response is that there is a quicker response to the antigen during a second exposure to that antigen. It is the memory of the initial response that provides the booster effect. For convenience, the specific immune response may be divided into two parts:

(1) the humoral response and

(2) the cellular response to a given antigen. As we shall see, however, both responses are mediated through the lymphocyte. Humoral responses are antibodies produced in response to a given antigen, and these antibodies are proteins, have similar structures, and can be divided into various classes of immunoglobulins. Cellular responses are established by cells and can only be transferred by cells.

Up to the 1940s the general dogma held that only antibodies were involved in the immune response. Dr. Merrill Chase, who began his experiments in a laboratory devoted primarily to the humoral response, clearly showed in a series of elegant experiments that immunity was not just humoral but that a cellular response by the lymphocytes could also produce immunity. Some of the best examples of the power of cellular immunity may be found in the many experiments in which transfer of cells can induce autoimmune disease in animals and humans as well as rejection of an organ graft in both animals and humans by cells.

 The separation of human and cellular immunity was further advanced by the study of immuno      deficient humans and animals. For example, thymectomized or congenitally athymic animals as well as humans cannot carry out graft rejection, yet they are capable of producing some antibody responses. The reverse is also true. Children (and animals) who have an immune defi cit in the humoral response do not make antibodies but can reject grafts and appear to handle viral, fungal, and some bacterial infections quite well. An extraordinary fi nding by Good and colleagues in studying the cloacal lymphoid organ in chickens revealed that, with removal of the bursa Fabricius, these animals lost their ability to produce antibodies and yet retained the ability to reject grafts.

Out of these and many other contributions, a clearer picture of the division of efforts by lymphocytes begins to emerge. Since cellular immune responses require an intact thymus, cellular immune responses are mediated through the T lymphocytes (thymus), while antibody-producing cells, which are dependent on the bone marrow (the bursa equivalent), are known as B (bursa) cells.

Several types of molecules play a vital role in the immune response, and we will deal with each in detail. Antigens, both foreign and self, are substances that may or may not provoke an immune response. Both T cells and B cells have receptors that recognize these antigens. In the case of B cells, antibodies on the surface are a major source (but not the only one) of antigen recognition, and once activated, they differentiate into plasma cells that produce large quantities of antibodies that are secreted into blood and body fluids to block the harmful effects of the antigen.

T cells have similar receptors known as T-cell receptors (TCR), and in the context of the major histocompatibility complex (MHC) molecules provide a means of self-recognition and T-lymphocyte effector functions. Often these effector functions are carried out by messages transmitted between these cells. These soluble messengers are called interleukins or cytokines.

CPT codes and Description

10021 Fna w/o image $191.45

10022 Fna w/image $186.13

10040 Acne surgery $96.24

10060 Drainage of skin abscess $173.42

10061 Drainage of skin abscess $311.04

10080 Drainage of pilonidal cyst $248.37

10081 Drainage of pilonidal cyst $291.94

10120 Remove foreign body $195.74

10121 Remove foreign body $440.43

10140 Drainage of hematoma/fluid $193.47

10160 Puncture drainage of lesion $144.33

10180 Complex drainage, wound $402.06

11000 Debride infected skin $86.11

11001 Debride infected skin add-on $38.92

11010 Debride skin, fx $795.45

11011 Debride skin/muscle, fx $943.70

11012 Debride skin/muscle/bone, fx $1,376.58

11040 Debride skin, partial $74.51

11041 Debride skin, full $108.39

11042 Debride skin/tissue $154.19

11043 Debride tissue/muscle $422.45

11044 Debride tissue/muscle/bone $552.38

11055 Trim skin lesion $43.15

11056 Trim skin lesions, 2 to 4 $54.18

11057 Trim skin lesions, over 4 $66.58

11100 Biopsy, skin lesion $132.92

11101 Biopsy, skin add-on $54.71

11200 Removal of skin tags $132.19

11201 Remove skin tags add-on $33.36

11300 Shave skin lesion $108.31

11301 Shave skin lesion $142.30

11302 Shave skin lesion $170.66

11303 Shave skin lesion $204.47

11305 Shave skin lesion $109.58

11306 Shave skin lesion $150.34

11307 Shave skin lesion $176.00

11308 Shave skin lesion $207.87

11310 Shave skin lesion $133.34

11311 Shave skin lesion $165.84

11312 Shave skin lesion $191.15

11313 Shave skin lesion $250.05

11400 Exc tr-ext b9+marg 0.5 <> 4.0 cm $429.82

11420 Exc h-f-nk-sp b9+marg 0.5 < $198.47 

11421 Exc h-f-nk-sp b9+marg 0.6-1 $253.70 

11422 Exc h-f-nk-sp b9+marg 1.1-2 $283.84 

11423 Exc h-f-nk-sp b9+marg 2.1-3 $336.99 

11424 Exc h-f-nk-sp b9+marg 3.1-4 $384.19 

11426 Exc h-f-nk-sp b9+marg > 4 cm $537.93

11440 Exc face-mm b9+marg 0.5 <> 4 cm $629.86

11450 Removal, sweat gland lesion $566.31

11451 Removal, sweat gland lesion $774.38

11462 Removal, sweat gland lesion $555.05

11463 Removal, sweat gland lesion $789.87

11470 Removal, sweat gland lesion $608.92

11471 Removal, sweat gland lesion $816.65

11600 Exc tr-ext mlg+marg 0.5 <> 4 cm $550.02

11620 Exc h-f-nk-sp mlg+marg 0.5 < $273.02 

11621 Exc h-f-nk-sp mlg+marg 0.6-1 $324.19 

11622 Exc h-f-nk-sp mlg+marg 1.1-2 $368.79 

11623 Exc h-f-nk-sp mlg+marg 2.1-3 $434.46 

11624 Exc h-f-nk-sp mlg+marg 3.1-4 $499.73 

11626 Exc h-f-nk-sp mlg+mar > 4 cm $658.35

11640 Exc face-mm malig+marg 0.5 < $290.13 

11641 Exc face-mm malig+marg 0.6-1 $378.15 

11642 Exc face-mm malig+marg 1.1-2 $437.79 

11643 Exc face-mm malig+marg 2.1-3 $506.50 

11644 Exc face-mm malig+marg 3.1-4 $640.25 

11646 Exc face-mm mlg+marg > 4 cm $862.44

11719 Trim nail(s) $30.25

11720 Debride nail, 1-5 $33.07

11721 Debride nail, 6 or more $44.35

11730 Removal of nail plate $147.01

11732 Remove nail plate, add-on $74.23

11740 Drain blood from under nail $87.52

11750 Removal of nail bed $292.06

11752 Remove nail bed/finger tip $416.20

11755 Biopsy, nail unit $175.96

11760 Repair of nail bed $251.87

11762 Reconstruction of nail bed $385.47

11765 Excision of nail fold, toe $132.07

11770 Removal of pilonidal lesion $347.09

11771 Removal of pilonidal lesion $843.64

11772 Removal of pilonidal lesion $1,042.25

11900 Injection into skin lesions $84.27

11901 Added skin lesions injection $106.55

11920 Correct skin color defects $264.44

11921 Correct skin color defects $315.18

11922 Correct skin color defects $64.12

11950 Therapy for contour defects $144.30

11951 Therapy for contour defects $196.25

11952 Therapy for contour defects $262.15

11954 Therapy for contour defects $314.03

11960 Insert tissue expander(s) $1,437.94

11970 Replace tissue expander $978.32

11971 Remove tissue expander(s) $656.46

11975 Insert contraceptive cap $201.15

11976 Removal of contraceptive cap $255.46

11977 Removal/reinsert contra cap $415.40

11980 Implant hormone pellet(s) $130.65

11981 Insert drug implant device $236.14

11982 Remove drug implant device $275.75

11983 Remove/insert drug implant $418.84

12001 Repair superficial wound(s) $270.13

12002 Repair superficial wound(s) $286.90

12004 Repair superficial wound(s) $336.96

12005 Repair superficial wound(s) $419.39

12006 Repair superficial wound(s) $474.36

12007 Repair superficial wound(s) $547.32

12011 Repair superficial wound(s) $285.97

12013 Repair superficial wound(s) $292.91

12014 Repair superficial wound(s) $364.90

12015 Repair superficial wound(s) $420.05

12016 Repair superficial wound(s) $493.09

12017 Repair superficial wound(s) $498.58

12018 Repair superficial wound(s) $587.35

12020 Closure of split wound $291.94

12021 Closure of split wound $265.08

12031 Layer closure of wound(s) $277.92

12032 Layer closure of wound(s) $359.95

12034 Layer closure of wound(s) $444.87

12035 Layer closure of wound(s) $528.67

12036 Layer closure of wound(s) $620.36

12037 Layer closure of wound(s) $711.99

12041 Layer closure of wound(s) $310.97

12042 Layer closure of wound(s) $389.71

12044 Layer closure of wound(s) $464.74

12045 Layer closure of wound(s) $537.80

12046 Layer closure of wound(s) $674.67

12047 Layer closure of wound(s) $766.30

12051 Layer closure of wound(s) $389.58

12052 Layer closure of wound(s) $432.30

12053 Layer closure of wound(s) $462.91

12054 Layer closure of wound(s) $511.64

12055 Layer closure of wound(s) $657.04

12056 Layer closure of wound(s) $873.80

12057 Layer closure of wound(s) $884.87

13100 Repair of wound or lesion $289.93

13101 Repair of wound or lesion $523.23

13102 Repair wound/lesion add-on $147.66

13120 Repair of wound or lesion $401.40

13121 Repair of wound or lesion $606.21

13122 Repair wound/lesion add-on $172.23

13131 Repair of wound or lesion $542.40

13132 Repair of wound or lesion $779.15

13133 Repair wound/lesion add-on $252.67

13150 Repair of wound or lesion $404.66

13151 Repair of wound or lesion $694.68

13152 Repair of wound or lesion $906.32

13153 Repair wound/lesion add-on $277.53

13160 Late closure of wound $974.53

14000 Skin tissue rearrangement $1,044.54

14001 Skin tissue rearrangement $1,342.85

14020 Skin tissue rearrangement $1,143.28

14021 Skin tissue rearrangement $1,497.67

14040 Skin tissue rearrangement $1,177.58

14041 Skin tissue rearrangement $1,618.56

14060 Skin tissue rearrangement $1,283.48

14061 Skin tissue rearrangement $1,749.90

14300 Skin tissue rearrangement $1,683.45

14350 Skin tissue rearrangement $1,251.99

15000 Skin graft $575.70

15001 Skin graft add-on $172.77

15050 Skin pinch graft $750.24

15100 Skin split graft $1,455.70

15101 Skin split graft add-on $399.68

15120 Skin split graft $1,512.87

15121 Skin split graft add-on $526.03

15200 Skin full graft $1,131.20

15201 Skin full graft add-on $176.00

15220 Skin full graft $1,344.17

15221 Skin full graft add-on $156.32

15240 Skin full graft $1,406.05

15241 Skin full graft add-on $245.93

15260 Skin full graft $1,456.02

15261 Skin full graft add-on $361.00

15342 Cultured skin graft, 25 cm $204.44

15343 Culture skn graft addl 25 cm $37.94

15350 Skin homograft $839.26

15351 Skin homograft add-on $143.85

15400 Skin heterograft $602.20

15401 Skin heterograft add-on $163.13

15570 Form skin pedicle flap $1,358.12

15572 Form skin pedicle flap $1,306.84

15574 Form skin pedicle flap $1,380.28

15576 Form skin pedicle flap $1,324.50

15600 Skin graft $635.22

15610 Skin graft $447.81

15620 Skin graft $744.82

15630 Skin graft $726.78

15650 Transfer skin pedicle flap $771.75

15732 Muscle-skin graft, head/neck $2,634.74

15734 Muscle-skin graft, trunk $2,633.35

15736 Muscle-skin graft, arm $2,537.48

15738 Muscle-skin graft, leg $2,650.96

15740 Island pedicle flap graft $1,465.05

15750 Neurovascular pedicle graft $1,520.94

15756 Free myo/skin flap microvasc $4,180.10

15757 Free skin flap, microvasc $4,262.33

15758 Free fascial flap, microvasc $4,258.45

15760 Composite skin graft $1,350.27

15770 Derma-fat-fascia graft $1,053.63

15775 Hair transplant punch grafts $302.52

15776 Hair transplant punch grafts $485.24

15780 Abrasion treatment of skin $1,047.20

15781 Abrasion treatment of skin $741.09

15782 Abrasion treatment of skin $626.47

15783 Abrasion treatment of skin $474.36

15786 Abrasion, lesion, single $160.96

15787 Abrasion, lesions, add-on $47.36

15788 Chemical peel, face, epiderm $390.49

15789 Chemical peel, face, dermal $817.92

15792 Chemical peel, nonfacial $360.57

15793 Chemical peel, nonfacial $570.77

15810 Salabrasion $382.29

15811 Salabrasion $514.67

15819 Plastic surgery, neck $1,227.30

15820 Revision of lower eyelid $867.79

15821 Revision of lower eyelid $936.86

15822 Revision of upper eyelid $740.14

15823 Revision of upper eyelid $1,075.42

15824 Removal of forehead wrinkles $1,514.77

15825 Removal of neck wrinkles $1,295.81

15826 Removal of brow wrinkles $1,094.72

15828 Removal of face wrinkles $3,704.15

15829 Removal of skin wrinkles $3,704.15

15831 Excise excessive skin tissue $1,544.24

15832 Excise excessive skin tissue $1,490.99

15833 Excise excessive skin tissue $1,408.70

15834 Excise excessive skin tissue $1,388.23

15835 Excise excessive skin tissue $1,701.47

15836 Excise excessive skin tissue $1,205.00

15837 Excise excessive skin tissue $1,204.90

15838 Excise excessive skin tissue $974.98

15839 Excise excessive skin tissue $1,275.82

15840 Graft for face nerve palsy $1,728.28

15841 Graft for face nerve palsy $2,882.64

15842 Flap for face nerve palsy $4,579.28

15845 Skin and muscle repair, face $1,614.51

15850 Removal of sutures $168.74

15851 Removal of sutures $184.70

15852 Dressing change not for burn $195.71

15860 Test for blood flow in graft $239.23

15876 Suction assisted lipectomy $893.57

15877 Suction assisted lipectomy $1,605.56

15878 Suction assisted lipectomy $893.57

15879 Suction assisted lipectomy $1,605.56

15920 Removal of tail bone ulcer $1,013.44

15922 Removal of tail bone ulcer $1,285.70

15931 Remove sacrum pressure sore $1,124.55

15933 Remove sacrum pressure sore $1,402.36

15934 Remove sacrum pressure sore $1,550.35

15935 Remove sacrum pressure sore $1,867.00

15936 Remove sacrum pressure sore $1,553.07

15937 Remove sacrum pressure sore $1,807.76

15940 Remove hip pressure sore $1,166.10

15941 Remove hip pressure sore $1,562.35

15944 Remove hip pressure sore $1,503.32

15945 Remove hip pressure sore $1,673.63

15946 Remove hip pressure sore $2,696.60

15950 Remove thigh pressure sore $583.09

15951 Remove thigh pressure sore $1,393.34

15952 Remove thigh pressure sore $1,437.51

15953 Remove thigh pressure sore $1,623.02

15956 Remove thigh pressure sore $1,972.35

15958 Remove thigh pressure sore $1,989.33

15999 Removal of pressure sore $0.00

16000 Initial treatment of burn(s) $92.81

16010 Treatment of burn(s) $113.15

16015 Treatment of burn(s) $263.92

16020 Treatment of burn(s) $131.36

16025 Treatment of burn(s) $182.42

16030 Treatment of burn(s) $314.33

16035 Incision of burn scab, initi $395.23

16036 Escharotomy; add’l incision $157.78

17000 Destroy benign/premlg lesion $113.03

17003 Destroy lesions, 2-14 $19.12

17004 Destroy lesions, 15 or more $372.87

17106 Destruction of skin lesions $623.85

17107 Destruction of skin lesions $1,222.96

17108 Destruction of skin lesions $1,254.91

17110 Destruct lesion, 1-14 $134.02

17111 Destruct lesion, 15 or more $145.01

17250 Chemical cautery, tissue $119.04

17260 Destruction of skin lesions $157.80

17261 Destruction of skin lesions $200.96

17262 Destruction of skin lesions $250.86

17263 Destruction of skin lesions $279.62

17264 Destruction of skin lesions $301.83

17266 Destruction of skin lesions $353.39

17270 Destruction of skin lesions $218.70

17271 Destruction of skin lesions $236.91

17272 Destruction of skin lesions $167.62

17273 Destruction of skin lesions $309.01

17274 Destruction of skin lesions $375.50

17276 Destruction of skin lesions $449.61

17280 Destruction of skin lesions $200.96

17281 Destruction of skin lesions $262.69

17282 Destruction of skin lesions $305.51

17283 Destruction of skin lesions $377.85

17284 Destruction of skin lesions $447.95

17286 Destruction of skin lesions $595.50

17304 1 stage mohs, up to 5 spec $1,088.42

17305 2 stage mohs, up to 5 spec $464.27

17306 3 stage mohs, up to 5 spec $481.32

17307 Mohs addl stage up to 5 spec $477.88

17310 Mohs any stage > 5 spec each $111.96

17340 Cryotherapy of skin $83.94

17360 Skin peel therapy $125.82

17380 Hair removal by electrolysis $128.11

17999 Skin tissue procedure $0.00

19000 Drainage of breast lesion $165.32

19001 Drain breast lesion add-on $55.98

19020 Incision of breast lesion $693.34

19030 Injection for breast x-ray $209.41

19100 Bx breast percut w/o image $235.27

19101 Biopsy of breast, open $568.60

19102 Bx breast percut w/image $428.86

19103 Bx breast percut w/device $667.85

19110 Nipple exploration $739.23

19112 Excise breast duct fistula $688.41

19120 Removal of breast lesion $753.09

19125 Excision, breast lesion $809.69

19126 Excision, addl breast lesion $300.68

19140 Removal of breast tissue $906.59

19160 Removal of breast tissue $709.45

19162 Remove breast tissue, nodes $1,505.02

19180 Removal of breast $1,041.11

19182 Removal of breast $940.22

19200 Removal of breast $1,771.16

19220 Removal of breast $1,808.29

19240 Removal of breast $1,830.22

19260 Removal of chest wall lesion $1,997.36

19271 Revision of chest wall $2,758.17

19272 Extensive chest wall surgery $3,032.43

19290 Place needle wire, breast $304.48

19291 Place needle wire, breast $163.83

19295 Place breast clip, percut $191.06

19316 Suspension of breast $1,367.00

19318 Reduction of large breast $2,005.97

19324 Enlarge breast $800.89

19325 Enlarge breast with implant $1,121.34

19328 Removal of breast implant $797.84

19330 Removal of implant material $1,017.55

19340 Immediate breast prosthesis $714.86

19342 Delayed breast prosthesis $1,502.49

19350 Breast reconstruction $1,459.56

19355 Correct inverted nipple(s) $1,277.14

19357 Breast reconstruction $2,388.32

19361 Breast reconstruction $2,333.08

19364 Breast reconstruction $4,846.59

19366 Breast reconstruction $2,453.94

19367 Breast reconstruction $3,174.07

19368 Breast reconstruction $3,957.11

19369 Breast reconstruction $3,720.38

19370 Surgery of breast capsule $1,114.54

19371 Removal of breast capsule $1,281.13

19380 Revise breast reconstruction $753.90

19396 Design custom breast implant $341.76

19499 Breast surgery procedure $0.00

Medical Biling Coding from Home? and Accredited Medial Coding and Billing Training in Illinois

Coders with a number of years of experience may want to set up their own business from the comfort of their home. Thorough understanding of the medical coding and billing industry, as well as technical skills, high self-motivation and organizational ability, and experience will be the foundation upon which this can be achieved.

Also determination, the drive to be independent, and well respected credentials are powerful resources for success. Also, people who are practical, logical, perceptive, observant, methodical, good planners, tennacious, sound decision makers, natural team leaders, good with facts and figures, and have a reputation for firmness and a no-nonsense attitude to life can do well running their own business as an independent contractor or consultant in medical coding and billing.

Hidden Pitfalls of Taking Online Courses

With our modern society's busy schedules and lifestyles distance education over the Internet provides e-learners with the convenience, flexibility, and the ability to study anywhere, any time without being on campus. 

However, just because a course is offered online and requires a fee to sign up doesn't automatically mean the program is accredited, even if the provider claims it is. Often, the certificate or diploma e-learners will receive upon successful completion of an online course is not even worth the paper it is printed on.

A Simple Word of Caution

Rule of thumb is: online courses are seldom accredited, or approved by the board of education unless they truly have met or exceed established national standards. The application process for reviews and approval is tedious and lengthy. 

Online training providers, non-traditional universities, and so called virtual colleges who offer distance learning programs have different accreditation standards than brick-and-mortar universities, colleges, and vocational training institutions. 

These institutions who went through the process and are approved will always have their program's accreditation status visibly posted on their website and online course catalogs.

Awareness is the Key!The Internet serves as a great information resource and education portal, but at the same time, it also is the perfect breeding ground for different types of scams. 

It is important that potential students recognize this, and understand the difference between fully accredited vs. illegitimate and non-accredited programs. 

If not, then the e-learner might be in for a rude awakening in the end, when after successfully completing an online course they find out they have nothing to show, and are not permitted to sit for any national certification examinations.

E-learners should be careful to choose courses that meet their individual educational needs to ensure that they don't waste their money and time. 

Some just need a refresher course for personal and professional enhancement and a low cost, non-transferrable, non-accredited course will do just fine. 

Others may need proper vocational training to receive a much desired promotion, or to achieve specific educational goals that will allow them advance into a new position or career. 

Then it is vitally important that these individuals graduate from courses that are accredited not just by any, but by the right organization, such as, for example the U.S. Department of Education, Council for Higher Education Accreditation (CHEA), Commission on Accreditation of Allied Health Education Programs (CAAHEP), Accrediting Bureau of Health Education Schools (ABHES), or the Joint Commission on Accreditation of Healthcare Organizations (JCAHO).

But How Can You Tell?

Web page advertisements that contain text, images, seals, and any profound sounding designations that a vocational training school and their programs are accredited containing words such as approved, accredited, accreditation pending, authorized, chartered, licensed, empowered, sponsored, recognized, and registered should be critically examined to determine whether these claims are merely common catch phrases, or the assertions are legit. 

It is always prudent before joining any programs to get in touch with the provider of the courses to ask questions, and to also contact the accrediting organization to find out whether a program is truly legitimately accredited by them, and to confirm the quality of the online training courses.

Accredited Medial Coding and Billing Training in Illinois

If you live in Illinois I highly encourage you to check out the Computer Systems Institute (CSI). 

Here is why: CSI offers comprehensive accredited vocational training programs that lead toward the necessary knowledge and skills to perform proficiently and successfully in a medical coding and billing job! 

CSI prepares you for industry-recognized certifications. Earned credit hours can be transferred to major institutions and applied toward a desired degree. It's definitely worth taking a look!!! 

Illinois CSI Campuses are located in the following communities: 

Chicago

Skokie

Lombard

Gurne

Every healthcare provider, whether a medical doctor, podiatrists, dentist, or surgeon that delivers a service receives money for these services. While most of them prefer to collect payment from patients at the end of the office visit, the majority of their fees are processed by filing a claim with the patient's health insurance provider, managed care organization, or government entities.

Coding for services in healthcare is complicated and therefore employers prefer to hire trained, and often, certified individuals to ascertain that their coder is proficient and familiar with different types of insurance plans and codes, and knows how to process and submit claims electronically, and enter codes into databases. They must also be able to collect payments, make adjustments, interpret EOB's, handle denied claims, and process appeals.

Eventually, an experienced medical record coder and biller may advance into higher more interesting positions, such as a senior technician who specializes in coding, particularly in the realm of Medicare coding, or in tumor registry.

Changes to Medicare Infusion and Injection Coding

I just came across a very interesting web site that should proove to be very helpful to those working in medical coding and billing. I found it while surfing the Internet to find any new rules and important changes in coding and billing. 

The article is published at Medical News today and titled: Medicare Infusion and Injection Coding/Payment Changes 2005. Here is a brief summary followed by the URL link to the web page so you can read the full article: 

There are new rules and regulations that will affect the way healthcare providers code infectious diseases and reimbursement for office-based outpatient infusions and injections provided to Medicare patients. 

Centers for Medicare and Medicaid Services has issued a series of new temporary "G" codes that replace current infusion codes (90780 and 90781) and other injection codes as of January 1, 2005. The 2006 CPT Manual will incorporate these G codes and make them permanent. 

These new CPT codes will be published in fall of 2005. While the new infusion codes will make billing more complex, they also describe the work being performed more accurately, which should be beneficial in the long-term. 

EOB Question

Today I finally received a comment from a person that was NOT a medical coder or working in the medical billing industry. The form was sent through the Medical Coding and Billing .com web site contact form by the other part of medical coding and billing, the consumer (recipient of medical services). Nice to know, that such a broad audience visits my site and finds it useful as well. 

The question was: What exactly is the EOB, I mean, what do the letters stand for. 

Simple: EOB is short for Explanation of Benefits which is a notification sent by the medical insurance company administrators after processing a medial insurance claim. 

The EOB explains the total amount the health care provider billed for medical services, the amount paid under the insurance contract, and who was paid. Patients should keep a copy of their bills from the health care provider of medical services to compare them to the EOB.