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:
Film screen mammography, both breasts.
Reason for procedure
Comparison to previous exams
Comparison was made to exam from 11/14/2001.
The breasts are heterogeneously dense. This may lower the sensitivity of mammography.
No significant masses, calcifications, or other abnormalities are present. There is no significant change from the prior exam.
BI-RADS® Category 1: Negative. Recommend normal interval follow-up in 12 months.
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|
|188.8.131.52||Procedure reported||Film screen mammography, both breasts.||4202/6053|
|1.2.2||Reason for procedure||4202/6052|
|184.108.40.206||Reason for procedure||Screening||4202/6053|
|1.2.3||Comparison to previous exams||4202/6052|
|220.127.116.11||Comparison to previous exams||Comparison was made to exam from 11/14/2001.||4202/6053|
|18.104.22.168||Breast composition||The breasts are heterogeneously dense. This may lower the sensitivity of mammography.||4202/6053|
|22.214.171.124||Finding||No significant masses, calcifications, or other abnormalities are present. There is no significant change from the prior exam.||4202/6053|
|126.96.36.199||Impression||BI-RADS® Category 1: Negative. Recommend normal interval follow-up in 12 months.||4202/6053|
|1.3.1||Procedure reported||Film Screen Mammography||4201/6050|
|188.8.131.52||Reason for procedure||Screening||4201/6051|
|184.108.40.206||Breast composition||Heterogeneously dense||4205/6000|
|220.127.116.11||Assessment Category||1 – Negative||4203/6026|
|18.104.22.168||Recommended Follow-up||Normal interval follow-up||4203/6028|