Q.2.2 Example 2: Screening Mammogram With Negative Findings
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### 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

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