Q.2.3 Example 3: Diagnostic Mammogram - Unilateral

A diagnostic mammogram was prompted by a clinical finding. The result is a probably benign finding with a short interval follow-up of the left breast. This report provides the narrative text with more extensive supplementary data.

Report Sample:

Procedure reported

Film screen mammography, left breast.

Reason for procedure

Non-bloody discharge left breast.

Breast composition

The breast is almost entirely fat.

Findings

Film screen mammograms were performed. There are heterogeneous calcifications regionally distributed in the 1 o’clock upper outer quadrant, anterior region of the left breast. There is an increase in the number of calcifications from the prior exam.

Impressions

BI-RADS® Category 3: Probably Benign Finding. Short interval follow-up of the left breast is recommended in 6 months.

Table Q.2-3: Breast Imaging Report Content for Example 3

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, left breast. 4202/6053
1.2.2 Reason for procedure 4202/6052
1.2.2.1 Reason for procedure Non-bloody discharge left breast. 4202/6053
1.2.3 Breast composition 4202/6052
1.2.3.1 Breast composition The breast is almost entirely fat. 4202/6053
1.2.4 Findings 4202/6052
1.2.4.1 Finding Film screen mammograms were performed. There are heterogeneous calcifications regionally distributed in the 1 o’clock upper outer quadrant, anterior region of the left breast. There is an increase in the number of calcifications from the prior exam. 4202/6053
1.2.5 Impressions 4202/6052
1.2.5.1 Impression BI-RADS® Category 3: Probably Benign Finding. Short interval follow-up of the left breast is recommended in 6 months. 4202/6053
1.3 Supplementary Data 4208
1.3.1 Procedure reported Film Screen Mammography 4201/6050
1.3.1.1 Laterality Left breast 4201/6022
1.3.1.2 Reason for procedure Clinical Finding 4201/6051
1.3.1.2.1 Clinical Finding Non-bloody discharge 4201/6055
1.3.1.2.1.1 Laterality Left breast 4201/6022
1.3.2 Breast composition 4205
1.3.2.1 Breast composition Almost entirely fat 4205/6000
1.3.2.1.1 Laterality Left breast 4205/6022
1.3.3 Findings 4206
1.3.3.1 Finding Calcification of breast 4206/6054
1.3.3.1.1 Assessment Category 3 – Probably Benign Finding – short interval follow-up 4203/6026
1.3.3.1.2 Recommended Follow-up Follow-up at short interval (1-11 months) 4203/6028
1.3.3.1.2.1 Laterality Left breast 4203/6022
1.3.3.1.2.2 Recommended Follow-up Interval 6 months 4203/6046
1.3.3.1.3 Clockface or region 1 o’clock position 4206/6018
1.3.3.1.4 Quadrant location Upper outer quadrant of breast 4206/6020
1.3.3.1.5 Depth Anterior 4206/6024
1.3.3.1.6 Calcification Type Heterogeneous calcification 4206/6010
1.3.3.1.7 Calcification Distribution Regional calcification distribution 4206/6012
1.3.3.1.8 Change since last mammogram Increase in number of calcifications 4206/6002