Q.2 Breast Imaging Report Examples

Q.2 Breast Imaging Report Examples (Current)
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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