The following are simple illustrations of encoding Mammography procedure based Breast Imaging Reports.
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 |
||
|
1.1 |
Language of Content Item and Descendants |
English |
|
|
1.2 |
Narrative Summary |
||
|
1.2.1 |
Procedure reported |
||
|
1.2.1.1 |
Procedure reported |
Film screen mammography, both breasts. |
|
|
1.2.2 |
Reason for procedure |
||
|
1.2.2.1 |
Reason for procedure |
Screening |
|
|
1.2.3 |
Findings |
||
|
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. |
|
|
1.2.4 |
Impressions |
||
|
1.2.4.1 |
Impression |
BI-RADS® Category 1: Negative. Recommend normal interval follow-up in 12 months. |
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 |
||
|
1.1 |
Language of Content Item and Descendants |
English |
|
|
1.2 |
Narrative Summary |
||
|
1.2.1 |
Procedure reported |
||
|
1.2.1.1 |
Procedure reported |
Film screen mammography, both breasts. |
|
|
1.2.2 |
Reason for procedure |
||
|
1.2.2.1 |
Reason for procedure |
Screening |
|
|
1.2.3 |
Comparison to previous exams |
||
|
1.2.3.1 |
Comparison to previous exams |
Comparison was made to exam from 11/14/2001. |
|
|
1.2.4 |
Breast composition |
||
|
1.2.4.1 |
Breast composition |
The breasts are heterogeneously dense. This may lower the sensitivity of mammography. |
|
|
1.2.5 |
Findings |
||
|
1.2.5.1 |
Finding |
No significant masses, calcifications, or other abnormalities are present. There is no significant change from the prior exam. |
|
|
1.2.6 |
Impressions |
||
|
1.2.6.1 |
Impression |
BI-RADS® Category 1: Negative. Recommend normal interval follow-up in 12 months. |
|
|
1.2.7 |
Overall Assessment |
||
|
1.2.7.1 |
Overall Assessment |
Negative |
|
|
1.3 |
Supplementary Data |
||
|
1.3.1 |
Procedure reported |
Film Screen Mammography |
|
|
1.3.1.1 |
Laterality |
Both breasts |
|
|
1.3.1.2 |
Reason for procedure |
Screening |
|
|
1.3.2 |
Breast composition |
||
|
1.3.2.1 |
Breast composition |
Heterogeneously dense |
|
|
1.3.2.1.1 |
Laterality |
Both breasts |
|
|
1.3.3 |
Overall Assessment |
||
|
1.3.3.1 |
Assessment Category |
1 - Negative |
|
|
1.3.3.2 |
Recommended Follow-up |
Normal interval follow-up |
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 |
||
|
1.1 |
Language of Content Item and Descendants |
English |
|
|
1.2 |
Narrative Summary |
||
|
1.2.1 |
Procedure reported |
||
|
1.2.1.1 |
Procedure reported |
Film screen mammography, left breast. |
|
|
1.2.2 |
Reason for procedure |
||
|
1.2.2.1 |
Reason for procedure |
Non-bloody discharge left breast. |
|
|
1.2.3 |
Breast composition |
||
|
1.2.3.1 |
Breast composition |
The breast is almost entirely fat. |
|
|
1.2.4 |
Findings |
||
|
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. |
|
|
1.2.5 |
Impressions |
||
|
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. |
|
|
1.3 |
Supplementary Data |
||
|
1.3.1 |
Procedure reported |
Film Screen Mammography |
|
|
1.3.1.1 |
Laterality |
Left breast |
|
|
1.3.1.2 |
Reason for procedure |
Clinical Finding |
|
|
1.3.1.2.1 |
Clinical Finding |
Non-bloody discharge |
|
|
1.3.1.2.1.1 |
Laterality |
Left breast |
|
|
1.3.2 |
Breast composition |
||
|
1.3.2.1 |
Breast composition |
Almost entirely fat |
|
|
1.3.2.1.1 |
Laterality |
Left breast |
|
|
1.3.3 |
Findings |
||
|
1.3.3.1 |
Finding |
Calcification of breast |
|
|
1.3.3.1.1 |
Assessment Category |
3 - Probably Benign Finding - short interval follow-up |
|
|
1.3.3.1.2 |
Recommended Follow-up |
Follow-up at short interval (1-11 months) |
|
|
1.3.3.1.2.1 |
Laterality |
Left breast |
|
|
1.3.3.1.2.2 |
Recommended Follow-up Interval |
6 months |
|
|
1.3.3.1.3 |
Clockface or region |
1 o'clock position |
|
|
1.3.3.1.4 |
Quadrant location |
Upper outer quadrant of breast |
|
|
1.3.3.1.5 |
Depth |
Anterior |
|
|
1.3.3.1.6 |
Calcification Type |
Heterogeneous calcification |
|
|
1.3.3.1.7 |
Calcification Distribution |
Regional calcification distribution |
|
|
1.3.3.1.8 |
Change since last mammogram |
Increase in number of calcifications |
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 |
||
|
1.1 |
Language of Content Item and Descendants |
English |
|
|
1.2 |
Narrative Summary |
||
|
1.2.1 |
Procedure reported |
||
|
1.2.1.1 |
Procedure reported |
Film screen mammography, left breast; Ultrasound procedure, left breast. |
|
|
1.2.2 |
Reason for procedure |
||
|
1.2.2.1 |
Reason for procedure |
Additional evaluation requested at current screening. |
|
|
1.2.3 |
Comparison to previous exams |
||
|
1.2.3.1 |
Comparison to previous exams |
Comparison was made to exam from 11/14/2001. |
|
|
1.2.4 |
Findings |
||
|
1.2.4.1 |
Finding |
Film Screen Mammography: A lobular mass with obscured margins is present measuring 7mm in the upper outer quadrant. |
|
|
1.2.5 |
Findings |
||
|
1.2.5.1 |
Finding |
Ultrasound demonstrates a simple cyst. |
|
|
1.2.6 |
Impressions |
||
|
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. |
|
|
1.2.7 |
Overall Assessment |
||
|
1.2.7.1 |
Overall Assessment |
Benign |
|
|
1.3 |
Supplementary Data |
||
|
1.3.1 |
Procedure reported |
Film Screen Mammography |
|
|
1.3.1.1 |
Laterality |
Left breast |
|
|
1.3.1.2 |
Reason for procedure |
Additional evaluation requested at current screening |
|
|
1.3.2 |
Procedure reported |
Ultrasound procedure |
|
|
1.3.2.1 |
Laterality |
Left breast |
|
|
1.3.2.2 |
Reason for procedure |
Additional evaluation requested at current screening |
|
|
1.3.3 |
Findings |
||
|
1.3.3.1 |
Procedure reported |
Film Screen Mammography |
|
|
1.3.3.1.1 |
Laterality |
Left breast |
|
|
1.3.3.1.2 |
Reason for procedure |
Additional evaluation requested at current screening |
|
|
1.3.3.2 |
Finding |
Mammographic breast mass |
|
|
1.3.3.2.1 |
Quadrant location |
Upper outer quadrant of breast |
|
|
1.3.3.2.2 |
Diameter |
7 mm |
|
|
1.3.3.2.3 |
Shape |
Lobular |
|
|
1.3.3.2.4 |
Margins |
Obscured lesion |
|
|
1.3.4 |
Findings |
||
|
1.3.4.1 |
Procedure reported |
Ultrasound procedure |
|
|
1.3.4.1.1 |
Laterality |
Left breast |
|
|
1.3.4.1.2 |
Reason for procedure |
Additional evaluation requested at current screening |
|
|
1.3.4.2 |
Finding |
Simple cyst of breast |
|
|
1.3.5 |
Overall Assessment |
||
|
1.3.5.1 |
Assessment Category |
2 - Benign Finding |