Andy is teaching a student intern how to assign CPT codes for the practice’s surgical reports. Kayla completed an introductory CPT coding course at school and is happy to put into practice that education. Andy explains that the CPT Surgery section contains subsections that are organized according to body systems. Then, subsections are further subdivided into categories according to specific organ or anatomic site and subcategories, which are usually in the following order:

Incision
Excision
Introduction or Removal
Repair, Endoscopy
Revision or Reconstruction
Destruction
Grafts
Suture
Other Procedures


What are three factors that must be considered when a coder abstracts information from the patient record to accurately assign CPT codes?