Mammography Workbook - CPSI Application Documentation

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2Mammography Workbookfor the entire department and for each individual radiologist.· Statistics on number of mammograms ordered per referring physician.In addition, a mammography database is available for creating ad hoc reports.The following tables contain site specific definitions utilized in the Mammography Application:· Radiologist Initials Table· Assessment Codes· Notification Codes· Recall Codes· Findings Codes· Size Codes – Size of the Cancer· Stage Code – Stage of the cancer (usually I- IV with some variations between)· Age: Path/Profile Table· Menarche Age: Profile Table· First Birth Age: Profile Table· True/False Pos/Neg Table· Technologist Initials Table· Biopsy Type Table· Mass Shape· Mass Region· Mass Margins· Mass Density Modifier· Mass Calcification· Breast Surgery Table· Breast Composition Table· Type MammogramAssessment codes are the Radiologist’s impression of the Mammogram. According to the© 2009 Computer Programs and Systems, Inc.
Introduction 3Mammography Quality Standards Act (MQSA) guidelines, each site must have at least ONEASSESSMENT CODE FOR EACH OF THE FOLLOWING CATEGORIES:· B – Benign· N – Negative· M – Highly suspicious of malignancy – Appropriate action should be taken· S – Suspicious Abnormality – Biopsy should be considered• If an “S” or “M” code is entered, the system will automatically make an entry Y (yes) in theBiopsy Required field (if used by site), when auto entry “Biopsy Rec” for access S & M is alsodefined as Y (yes).· P – Probable benign finding – Short Interval follow-up suggested, Classification needed• “N”egative or “U”nresolved· X – Unresolved, Patient never came back· 0 (zero): Need additional images, record is unresolved· If the facility is using American College of Radiology standards for assessment codes(BI-RADS), each facility must have at least one assessment code for each of the followingcategories:• 0 – (zero): Needs additional image evaluation• 1 – Negative• 2 – Benign Finding• 3 – Probably Benign Finding-Short interval follow-up suggested• 4 – Suspicious Abnormality-Biopsy should be considered.• 5 – Highly Suggestive of Malignancy-Appropriate action should be taken.• 6 – Known Biopsy-Proven Malignancy-Appropriate action should be taken.NOTE: The BIRAD 6 code is an optional code to be used if a site deems necessary. This categoryis reserved for lesions identified on the imaging study with biopsy proof or malignancy prior todefinitive therapy.This category is appropriate for second opinions on findings previously biopsiedand shown to be malignant.Findings codes are only entered on those patients where a breast specimen has been obtained(either Fine Needle Aspiration (FNA) or Biopsy). These findings will come from the Pathologyreport. Each site MUST HAVE AT LEAST ONE FINDING CODES FOR EACH OF THEFOLLOWING CATEGORIES:· C – Cancer· L – High Risk Lesion· Y – Cyst (Benign)· B – Benign (Any other benign finding other than a cyst.)· N – No findings (Patient did not have a recommended follow-up.)© 2009 Computer Programs and Systems, Inc.
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