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. |