Q.2.4 Example 4: Diagnostic Mammogram and Ultrasound - Unilateral

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.

Report Sample:

Procedure reported

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.

Findings

Film Screen Mammography: A lobular mass with obscured margins is present measuring 7mm in the upper outer quadrant.

Findings

Ultrasound demonstrates a simple cyst.

Impressions

BI-RADS® Category 2: Benign, no evidence of malignancy. Normal interval follow-up of both breasts is recommended in 12 months.

Overall Assessment

Benign

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
1.2 Narrative Summary 4202
1.2.1 Procedure reported 4202/6052
1.2.1.1 Procedure reported Film screen mammography, left breast; Ultrasound procedure, left breast. 4202/6053
1.2.2 Reason for procedure 4202/6052
1.2.2.1 Reason for procedure Additional evaluation requested at current 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 Findings 4202/6052
1.2.4.1 Finding Film Screen Mammography: A lobular mass with obscured margins is present measuring 7mm in the upper outer quadrant. 4202/6053
1.2.5 Findings 4202/6052
1.2.5.1 Finding Ultrasound demonstrates a simple cyst. 4202/6053
1.2.6 Impressions 4202/6052
1.2.6.1 Impression BI-RADS® Category 2: Benign, no evidence of malignancy. Normal interval follow-up of both breasts is recommended in 12 months. 4202/6053
1.2.7 Overall Assessment 4202/6052
1.2.7.1 Overall Assessment Benign 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 Additional evaluation requested at current screening 4201/6051
1.3.2 Procedure reported Ultrasound procedure 4201/6050
1.3.2.1 Laterality Left breast 4201/6022
1.3.2.2 Reason for procedure Additional evaluation requested at current screening 4201/6051
1.3.3 Findings 4206
1.3.3.1 Procedure reported Film Screen Mammography 4201/6050
1.3.3.1.1 Laterality Left breast 4201/6022
1.3.3.1.2 Reason for procedure Additional evaluation requested at current screening 4201/6051
1.3.3.2 Finding Mammographic breast mass 4206/6054
1.3.3.2.1 Quadrant location Upper outer quadrant of breast 4206/6020
1.3.3.2.2 Diameter 7 mm 1400/7470
1.3.3.2.3 Shape Lobular 4206/6004
1.3.3.2.4 Margins Obscured lesion 4206/6006
1.3.4 Findings 4206
1.3.4.1 Procedure reported Ultrasound procedure 4201/6050
1.3.4.1.1 Laterality Left breast 4201/6022
1.3.4.1.2 Reason for procedure Additional evaluation requested at current screening 4201/6051
1.3.4.2 Finding Simple cyst of breast 4206/6054
1.3.5 Overall Assessment 4208
1.3.5.1 Assessment Category 2 – Benign Finding 4203/6026