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Mammogram assessment category of incomplete: need additional imaging evaluation documented (RAD)

CPT4 code

Name of the Procedure:

Mammogram Assessment Category of Incomplete: Need Additional Imaging Evaluation (RAD)

Summary

A mammogram is an X-ray examination of the breast used to screen for breast cancer or evaluate breast changes. If the results are deemed "incomplete" or "need additional imaging evaluation," it means that the initial mammogram did not provide sufficient information, and further tests are required.

Purpose

The primary purpose of this additional imaging is to obtain a clearer and more detailed view of the breast tissue to determine if there are any abnormalities that require attention. The goal is to ensure accurate diagnosis and appropriate management of any detected issues.

Indications

  • Presence of unusual changes in the breast or underarm area, such as lumps or thickening.
  • Follow-up on inconclusive or unclear results from a screening mammogram.
  • A family history of breast cancer or other risk factors that warrant close monitoring.

Preparation

  • No special preparation is generally required.
  • Patients should inform their healthcare provider of any breast symptoms or issues prior to the examination.
  • Avoid using deodorants, antiperspirants, powders, lotions, or perfumes under the arms or on the breasts on the day of the exam, as these can interfere with the imaging.

Procedure Description

  1. The patient stands in front of a special X-ray machine.
  2. The technologist positions the breast on the machine’s plate.
  3. A plastic plate will then compress the breast to flatten the tissue.
  4. Additional views or different techniques, such as magnified or spot compression views, may be used to get a detailed image.
  5. The patient may be asked to hold their breath for a few seconds while the X-ray is taken.

Duration

Typically, an additional imaging evaluation takes about 30 minutes to an hour.

Setting

This procedure is usually performed in a hospital's radiology department or an accredited outpatient imaging center.

Personnel

  • Radiologic technologist to perform the imaging.
  • Radiologist to interpret the results.

Risks and Complications

  • Slight discomfort or pain during breast compression.
  • Very low radiation exposure.
  • Rarely, unnecessary anxiety if further testing shows the area is benign.

Benefits

  • Provides a clearer view of the breast tissue.
  • Helps in accurate diagnosis, potentially avoiding unnecessary biopsies.
  • Early detection of breast abnormalities, which can lead to early treatment and better outcomes.

Recovery

  • No recovery time is generally needed.
  • Patients can resume normal activities immediately after the procedure.
  • Follow-up appointments might be scheduled based on the results.

Alternatives

  • Breast ultrasound: Uses sound waves to produce images of the breast and may be used to evaluate findings on the mammogram.
  • Breast MRI: Offers a more detailed image, particularly useful for high-risk patients.
  • Clinical breast exam: Physical examination by a healthcare provider.

Patient Experience

During the procedure, patients may feel pressure and discomfort due to breast compression, but this typically lasts only a few seconds. Pain management is typically not needed, as discomfort is usually minimal. After the procedure, patients can expect to resume their regular daily activities without restrictions.

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