Q.2 Breast Imaging Report Examples
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## 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

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