Q.2.2 Example 2: Screening Mammogram with Negative Findings

A screening mammography case, i.e., there are typically four films and no suspicious abnormalities. The result is a negative mammogram with basic reporting. This example illustrates a report encoded as narrative text with minimal supplementary data, and follows BI-RADS® and MQSA:

Report Sample:

Procedure reported

Film screen mammography, both breasts.

Reason for procedure

Screening

Comparison to previous exams

Comparison was made to exam from 11/14/2001.

Breast composition

The breasts are heterogeneously dense. This may lower the sensitivity of mammography.

Findings

No significant masses, calcifications, or other abnormalities are present. There is no significant change from the prior exam.

Impressions

BI-RADS® Category 1: Negative. Recommend normal interval follow-up in 12 months.

Overall Assessment

Negative

TABLE Q.2-2: Breast Imaging Report Content for Example 2

Node Code Meaning of Concept Name Code Meaning or Example Value TID/CID
1 Breast Imaging Report 4200
1.1 Language of Content Item and Descendants English 1204
1.2 Narrative Summary 4202
1.2.1 Procedure reported 4202/6052
1.2.1.1 Procedure reported Film screen mammography, both breasts. 4202/6053
1.2.2 Reason for procedure 4202/6052
1.2.2.1 Reason for procedure Screening 4202/6053
1.2.3 Comparison to previous exams 4202/6052
1.2.3.1 Comparison to previous exams Comparison was made to exam from 11/14/2001. 4202/6053
1.2.4 Breast composition 4202/6052
1.2.4.1 Breast composition The breasts are heterogeneously dense. This may lower the sensitivity of mammography. 4202/6053
1.2.5 Findings 4202/6052
1.2.5.1 Finding No significant masses, calcifications, or other abnormalities are present. There is no significant change from the prior exam. 4202/6053
1.2.6 Impressions 4202/6052
1.2.6.1 Impression BI-RADS® Category 1: Negative. Recommend normal interval follow-up in 12 months. 4202/6053
1.2.7 Overall Assessment 4202/6052
1.2.7.1 Overall Assessment Negative 4202/6053
1.3 Supplementary Data 4208
1.3.1 Procedure reported Film Screen Mammography 4201/6050
1.3.1.1 Laterality Both breasts 4201/6022
1.3.1.2 Reason for procedure Screening 4201/6051
1.3.2 Breast composition 4205
1.3.2.1 Breast composition Heterogeneously dense 4205/6000
1.3.2.1.1 Laterality Both breasts 4205/6022
1.3.3 Overall Assessment 4208
1.3.3.1 Assessment Category 1 – Negative 4203/6026
1.3.3.2 Recommended Follow-up Normal interval follow-up 4203/6028