AMA Clinical Examples in Radiology - 2020 Issue 1 (Winter)
Bilateral Breast MRI With and Without Contrast with CAD
RADIOLOGY TEST CASE The radiology test case is provided for coding professionals to test their knowledge. Please take some time to review and code the case. Consider your answers as to how the procedure is reported in 2020. Once you are confident with your answer, turn to page 14 for the correct answer and discussion. Bilateral Breast MRI With and Without Contrast with CAD CLINICAL HISTORY High-risk patient with history of left breast cancer. Status-post left mastectomy with implant reconstruction. Status-post chemotherapy. Patient tested negative for breast cancer (BRCA) genetic mutation. No family history of breast cancer. TECHNIQUE Bilateral...
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Article Overview
This article presents a radiology test case for breast MRI coding professionals. It covers the exam context, technique, imaging findings, and impression for a bilateral breast MRI with contrast and CAD, along with the surrounding case-based discussion used to review reporting in 2020. The content is relevant to coders, radiology staff, and trainees who need to understand how the study is documented and categorized at a high level.
Why This Topic Matters
Breast MRI reporting can affect modality selection, coding accuracy, and interpretation of the documented exam components. This case helps readers assess whether the encounter involves MRI with contrast, CAD-supported post-processing, and breast imaging follow-up language.
Article Sections
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Clinical History
Summarizes the patient context and prior medical history relevant to the imaging study. It frames the reason the exam was performed without providing coding conclusions.
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Technique
Describes the imaging method, contrast administration, and post-processing workflow used for the breast MRI. The section supports recognition of the study type and documentation elements.
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Findings
Presents the breast MRI observations and comparison to a prior study. It includes the general structure of the radiology interpretation and associated imaging notes.
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Impression
Gives the final radiology assessment and follow-up language from the case. It also reflects the reporting framework used in breast imaging.
What You Will Learn
- How a breast MRI case is organized in a coding-oriented radiology example
- Which documentation elements are typically included in the history, technique, findings, and impression
- How contrast use and CAD-related post-processing are presented in the report
- How breast imaging reporting language is summarized in a case-based learning format
Who Should Read This
- Radiology coders
- Medical coders
- Radiology billing staff
- Coding educators
- Trainees reviewing breast imaging documentation
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