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:

Example Q.2-1. Report Sample: Narrative Text Only

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

TID 4200

1.1

Language of Content Item and Descendants

English

TID 1204

1.2

Narrative Summary

TID 4202

1.2.1

Procedure reported

TID 4202

CID 6052

1.2.1.1

Procedure reported

Film screen mammography, both breasts.

TID 4202

CID 6053

1.2.2

Reason for procedure

TID 4202

CID 6052

1.2.2.1

Reason for procedure

Screening

TID 4202

CID 6053

1.2.3

Findings

TID 4202

CID 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.

TID 4202

CID 6053

1.2.4

Impressions

TID 4202

CID 6052

1.2.4.1

Impression

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

TID 4202

CID 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:

Example Q.2-2. Report Sample: Narrative Text with Minimal Supplementary Data

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

TID 4200

1.1

Language of Content Item and Descendants

English

TID 1204

1.2

Narrative Summary

TID 4202

1.2.1

Procedure reported

TID 4202

CID 6052

1.2.1.1

Procedure reported

Film screen mammography, both breasts.

TID 4202

CID 6053

1.2.2

Reason for procedure

TID 4202

CID 6052

1.2.2.1

Reason for procedure

Screening

TID 4202

CID 6053

1.2.3

Comparison to previous exams

TID 4202

CID 6052

1.2.3.1

Comparison to previous exams

Comparison was made to exam from 11/14/2001.

TID 4202

CID 6053

1.2.4

Breast composition

TID 4202

CID 6052

1.2.4.1

Breast composition

The breasts are heterogeneously dense. This may lower the sensitivity of mammography.

TID 4202

CID 6053

1.2.5

Findings

TID 4202

CID 6052

1.2.5.1

Finding

No significant masses, calcifications, or other abnormalities are present. There is no significant change from the prior exam.

TID 4202

CID 6053

1.2.6

Impressions

TID 4202

CID 6052

1.2.6.1

Impression

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

TID 4202

CID 6053

1.2.7

Overall Assessment

TID 4202

CID 6052

1.2.7.1

Overall Assessment

Negative

TID 4202

CID 6053

1.3

Supplementary Data

TID 4208

1.3.1

Procedure reported

Film Screen Mammography

TID 4201

CID 6050

1.3.1.1

Laterality

Both breasts

TID 4201

CID 6022

1.3.1.2

Reason for procedure

Screening

TID 4201

CID 6051

1.3.2

Breast composition

TID 4205

1.3.2.1

Breast composition

Heterogeneously dense

TID 4205

CID 6000

1.3.2.1.1

Laterality

Both breasts

TID 4205

CID 6022

1.3.3

Overall Assessment

TID 4208

1.3.3.1

Assessment Category

1 - Negative

TID 4203

CID 6026

1.3.3.2

Recommended Follow-up

Normal interval follow-up

TID 4203

CID 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.

Example Q.2-3. Report Sample: Narrative Text with More Extensive Supplementary Data

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

TID 4200

1.1

Language of Content Item and Descendants

English

TID 1204

1.2

Narrative Summary

TID 4202

1.2.1

Procedure reported

TID 4202

CID 6052

1.2.1.1

Procedure reported

Film screen mammography, left breast.

TID 4202

CID 6053

1.2.2

Reason for procedure

TID 4202

CID 6052

1.2.2.1

Reason for procedure

Non-bloody discharge left breast.

TID 4202

CID 6053

1.2.3

Breast composition

TID 4202

CID 6052

1.2.3.1

Breast composition

The breast is almost entirely fat.

TID 4202

CID 6053

1.2.4

Findings

TID 4202

CID 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.

TID 4202

CID 6053

1.2.5

Impressions

TID 4202

CID 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.

TID 4202

CID 6053

1.3

Supplementary Data

TID 4208

1.3.1

Procedure reported

Film Screen Mammography

TID 4201

CID 6050

1.3.1.1

Laterality

Left breast

TID 4201

CID 6022

1.3.1.2

Reason for procedure

Clinical Finding

TID 4201

CID 6051

1.3.1.2.1

Clinical Finding

Non-bloody discharge

TID 4201

CID 6055

1.3.1.2.1.1

Laterality

Left breast

TID 4201

CID 6022

1.3.2

Breast composition

TID 4205

1.3.2.1

Breast composition

Almost entirely fat

TID 4205

CID 6000

1.3.2.1.1

Laterality

Left breast

TID 4205

CID 6022

1.3.3

Findings

TID 4206

1.3.3.1

Finding

Calcification of breast

TID 4206

CID 6054

1.3.3.1.1

Assessment Category

3 - Probably Benign Finding - short interval follow-up

TID 4203

CID 6026

1.3.3.1.2

Recommended Follow-up

Follow-up at short interval (1-11 months)

TID 4203

CID 6028

1.3.3.1.2.1

Laterality

Left breast

TID 4203

CID 6022

1.3.3.1.2.2

Recommended Follow-up Interval

6 months

TID 4203

CID 6046

1.3.3.1.3

Clockface or region

1 o'clock position

TID 4206

CID 6018

1.3.3.1.4

Quadrant location

Upper outer quadrant of breast

TID 4206

CID 6020

1.3.3.1.5

Depth

Anterior

TID 4206

CID 6024

1.3.3.1.6

Calcification Type

Heterogeneous calcification

TID 4206

CID 6010

1.3.3.1.7

Calcification Distribution

Regional calcification distribution

TID 4206

CID 6012

1.3.3.1.8

Change since last mammogram

Increase in number of calcifications

TID 4206

CID 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.

Example Q.2-4. Report Sample: Multiple Procedures, Narrative Text with Some Supplementary Data

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

TID 4200

1.1

Language of Content Item and Descendants

English

TID 1204

1.2

Narrative Summary

TID 4202

1.2.1

Procedure reported

TID 4202

CID 6052

1.2.1.1

Procedure reported

Film screen mammography, left breast; Ultrasound procedure, left breast.

TID 4202

CID 6053

1.2.2

Reason for procedure

TID 4202

CID 6052

1.2.2.1

Reason for procedure

Additional evaluation requested at current screening.

TID 4202

CID 6053

1.2.3

Comparison to previous exams

TID 4202

CID 6052

1.2.3.1

Comparison to previous exams

Comparison was made to exam from 11/14/2001.

TID 4202

CID 6053

1.2.4

Findings

TID 4202

CID 6052

1.2.4.1

Finding

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

TID 4202

CID 6053

1.2.5

Findings

TID 4202

CID 6052

1.2.5.1

Finding

Ultrasound demonstrates a simple cyst.

TID 4202

CID 6053

1.2.6

Impressions

TID 4202

CID 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.

TID 4202

CID 6053

1.2.7

Overall Assessment

TID 4202

CID 6052

1.2.7.1

Overall Assessment

Benign

TID 4202

CID 6053

1.3

Supplementary Data

TID 4208

1.3.1

Procedure reported

Film Screen Mammography

TID 4201

CID 6050

1.3.1.1

Laterality

Left breast

TID 4201

CID 6022

1.3.1.2

Reason for procedure

Additional evaluation requested at current screening

TID 4201

CID 6051

1.3.2

Procedure reported

Ultrasound procedure

TID 4201

CID 6050

1.3.2.1

Laterality

Left breast

TID 4201

CID 6022

1.3.2.2

Reason for procedure

Additional evaluation requested at current screening

TID 4201

CID 6051

1.3.3

Findings

TID 4206

1.3.3.1

Procedure reported

Film Screen Mammography

TID 4201

CID 6050

1.3.3.1.1

Laterality

Left breast

TID 4201

CID 6022

1.3.3.1.2

Reason for procedure

Additional evaluation requested at current screening

TID 4201

CID 6051

1.3.3.2

Finding

Mammographic breast mass

TID 4206

CID 6054

1.3.3.2.1

Quadrant location

Upper outer quadrant of breast

TID 4206

CID 6020

1.3.3.2.2

Diameter

7 mm

TID 1400

CID 7470

1.3.3.2.3

Shape

Lobular

TID 4206

CID 6004

1.3.3.2.4

Margins

Obscured lesion

TID 4206

CID 6006

1.3.4

Findings

TID 4206

1.3.4.1

Procedure reported

Ultrasound procedure

TID 4201

CID 6050

1.3.4.1.1

Laterality

Left breast

TID 4201

CID 6022

1.3.4.1.2

Reason for procedure

Additional evaluation requested at current screening

TID 4201

CID 6051

1.3.4.2

Finding

Simple cyst of breast

TID 4206

CID 6054

1.3.5

Overall Assessment

TID 4208

1.3.5.1

Assessment Category

2 - Benign Finding

TID 4203

CID 6026