Following a screening mammogram, the patient was asked to return for additional imaging and an ultrasound on the breast, for further evaluation of a mammographic mass. This example demonstrates a report on multiple breast imaging procedures. This report provides the narrative text with some supplementary data.
Film screen mammography, left breast; Ultrasound procedure, left breast.
Reason for procedure
Additional evaluation requested at current screening.
Comparison to previous exams
Comparison was made to exam from 11/14/2001.
Film Screen Mammography: A lobular mass with obscured margins is present measuring 7mm in the upper outer quadrant.
Ultrasound demonstrates a simple cyst.
BI-RADS® Category 2: Benign, no evidence of malignancy. Normal interval follow-up of both breasts is recommended in 12 months.
Table Q.2-4: Breast Imaging Report Content for Example 4
|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|
|18.104.22.168||Procedure reported||Film screen mammography, left breast; Ultrasound procedure, left breast.||4202/6053|
|1.2.2||Reason for procedure||4202/6052|
|22.214.171.124||Reason for procedure||Additional evaluation requested at current screening.||4202/6053|
|1.2.3||Comparison to previous exams||4202/6052|
|126.96.36.199||Comparison to previous exams||Comparison was made to exam from 11/14/2001.||4202/6053|
|188.8.131.52||Finding||Film Screen Mammography: A lobular mass with obscured margins is present measuring 7mm in the upper outer quadrant.||4202/6053|
|184.108.40.206||Finding||Ultrasound demonstrates a simple cyst.||4202/6053|
|220.127.116.11||Impression||BI-RADS® Category 2: Benign, no evidence of malignancy. Normal interval follow-up of both breasts is recommended in 12 months.||4202/6053|
|1.3.1||Procedure reported||Film Screen Mammography||4201/6050|
|18.104.22.168||Reason for procedure||Additional evaluation requested at current screening||4201/6051|
|1.3.2||Procedure reported||Ultrasound procedure||4201/6050|
|22.214.171.124||Reason for procedure||Additional evaluation requested at current screening||4201/6051|
|126.96.36.199||Procedure reported||Film Screen Mammography||4201/6050|
|188.8.131.52.2||Reason for procedure||Additional evaluation requested at current screening||4201/6051|
|184.108.40.206||Finding||Mammographic breast mass||4206/6054|
|220.127.116.11.1||Quadrant location||Upper outer quadrant of breast||4206/6020|
|18.104.22.168||Procedure reported||Ultrasound procedure||4201/6050|
|22.214.171.124.2||Reason for procedure||Additional evaluation requested at current screening||4201/6051|
|126.96.36.199||Finding||Simple cyst of breast||4206/6054|
|188.8.131.52||Assessment Category||2 – Benign Finding||4203/6026|