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Mammogram assessment category of benign, documented (RAD)

CPT4 code

Name of the Procedure:

Mammogram Assessment - Category: Benign, Documented (RAD)

Summary

A mammogram is a type of X-ray used to examine breast tissue for any signs of abnormalities. When categorized as benign, documented (RAD), the findings indicate that there is no evidence of cancer. This procedure ensures routine monitoring of the breast tissue to detect any changes over time.

Purpose

The main purpose of a benign mammogram assessment is to confirm that no cancerous changes are present in the breast tissue. Regular monitoring helps in early detection if any changes occur later. This assessment provides reassurance and helps in the early planning of any further investigations if needed in the future.

Indications

  • Routine breast cancer screening for women aged 40 and above.
  • Follow-up of previously identified benign breast changes.
  • Monitoring breast health in patients with a family history of breast cancer.

Preparation

  • Avoid applying deodorants, perfumes, or lotions on the day of the mammogram.
  • Inform the healthcare provider if you are pregnant or breastfeeding.
  • Wear a two-piece outfit to make it easier to undress from the waist up.

    Procedure Description

    1. You will be asked to undress from the waist up and wear a provided gown.
    2. The technologist will position your breast on the mammogram machine’s plate.
    3. Another plate will press down on your breast to spread out the tissue.
    4. The machine will take X-ray images of your breast from different angles.
    5. The process is repeated for the other breast.

Tools and Technology:

  • Mammogram machine (X-ray equipment).

No anesthesia or sedation is required for this non-invasive procedure.

Duration

The procedure typically takes about 20 to 30 minutes.

Setting

Mammograms are usually performed in a radiology department of a hospital, an outpatient clinic, or a specialized imaging center.

Personnel

  • Radiology technologist to operate the mammogram machine.
  • Radiologist to interpret the mammogram images and document findings.

Risks and Complications

  • Exposure to low levels of radiation, although the risk is minimal.
  • Temporary discomfort or pain due to breast compression during the imaging.

Benefits

  • Early detection of any breast tissue changes.
  • Reassurance if the findings confirm benign conditions.
  • Helps in planning preventative care and timely interventions if needed.

Recovery

  • You can resume normal activities immediately after the mammogram.
  • Some mild discomfort or tenderness may be felt temporarily.
  • Follow-up mammograms or additional tests may be scheduled as advised by the radiologist.

Alternatives

  • Ultrasound or MRI if more detailed imaging is required.
  • Clinical breast exams and self-exams to monitor changes over time.
  • Pros: Ultrasound and MRI provide more detailed images; clinical exams are non-invasive.
  • Cons: Ultrasound and MRI are more expensive and may not be as readily available.

Patient Experience

During the mammogram, you may feel brief discomfort as the breast is compressed. After the procedure, there is typically no lasting pain, and normal activities can be resumed immediately. Most patients experience a sense of reassurance following a benign assessment, although follow-up instructions will depend on individual findings.

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