Q.2 Breast Imaging Report Examples

The following are simple illustrations of encoding Mammography procedure based Breast Imaging Reports.

Q.2.1 Example 1: 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 only:

Report Sample:

Procedure reported

Film screen mammography, both breasts.

Reason for procedure

Screening

Findings

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.

Impressions

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

TABLE Q.2-1: Breast Image Report Content for Example 1

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 Findings 4202/6052
1.2.3.1 Finding 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. 4202/6053
1.2.4 Impressions 4202/6052
1.2.4.1 Impression BI-RADS® Category 1: Negative. Recommend normal interval follow-up in 12 months. 4202/6053

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

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

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