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Mammogram assessment category of probably benign, documented (RAD)

CPT4 code

Name of the Procedure:

Mammogram Assessment Category of Probably Benign, Documented (RAD)

  • Commonly referred to as "Probably Benign Mammogram" or "Category 3 Mammogram."

Summary

A probably benign mammogram assessment is a follow-up procedure used to evaluate breast tissue abnormalities that are unlikely to be cancerous. The goal is to monitor these findings over time to ensure they do not develop into something more serious.

Purpose

  • Medical Condition or Problem: Suspected non-cancerous abnormalities in breast tissue detected in a screening mammogram.
  • Goals/Expected Outcomes: To monitor changes over time and ensure early intervention if any suspicious developments occur.

Indications

  • Specific symptoms or conditions include:
    • Asymmetries
    • Tiny calcifications
    • Small, circumscribed masses
  • Patient criteria:
    • Women with initial screening mammograms showing findings that are unlikely to be malignant but warrant further observation.

Preparation

  • Pre-procedure instructions:
    • Avoid using deodorants, powders, or lotions on the day of the mammogram as they can affect imaging quality.
  • Diagnostic tests:
    • Previous mammograms for comparison.

Procedure Description

  • Steps:
    1. The patient undresses from the waist up and wears a provided gown.
    2. The patient stands in front of a mammography machine.
    3. A technologist positions and compresses each breast between two plates to obtain clear X-ray images.
  • Tools/Equipment: Mammography machine.
  • Anesthesia/Sedation: Not required.

Duration

  • The procedure typically takes 15 to 30 minutes.

Setting

  • The procedure is performed in a hospital radiology department or an outpatient imaging center.

Personnel

  • Healthcare professionals involved:
    • Radiologic technologist
    • Radiologist (interprets the images)

Risks and Complications

  • Common risks:
    • Discomfort or pain from breast compression.
  • Rare risks:
    • Exposure to low levels of radiation.
  • Possible complications:
    • False positives or negatives, leading to unnecessary anxiety or missed diagnosis.

Benefits

  • Expected Benefits:
    • Early detection and monitoring of breast abnormalities, allowing for prompt action if changes occur.
  • Realization Timeline:
    • Immediate reassurance if no changes are detected, or timely follow-up if monitoring reveals changes.

Recovery

  • Post-procedure care:
    • No specific care needed; patients can resume normal activities immediately.
  • Recovery time:
    • Immediate; no downtime required.
  • Follow-up:
    • Typically involves scheduled follow-up mammograms at 6-month intervals over 1 to 2 years.

Alternatives

  • Other treatment options:
    • Ultrasounds
    • MRI scans
    • Biopsies (if the findings are suspicious)
  • Pros and Cons of Alternatives:
    • Ultrasounds and MRI scans offer different imaging perspectives but may be more costly or less readily available.
    • Biopsies provide definitive diagnosis but are invasive.

Patient Experience

  • During the Procedure:
    • The patient may feel temporary discomfort due to breast compression.
  • After the Procedure:
    • Patients can expect no significant symptoms.
    • Pain management and comfort measures: Pain is minimal, and over-the-counter pain relief can be taken if necessary.

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