Q.2.2 Example 2: Screening Mammogram With Negative Findings

Q.2.2 Example 2: Screening Mammogram With Negative Findings (Current)
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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