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Johns Hopkins Medical Imaging

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Breast Screening and Imaging Appropriateness Criteria

On this page you will find best practice breast screening and imaging appropriateness criteria for the following:

Palpable Breast Lumps

breast icon

Most palpable breast lumps are benign, but a new palpable breast mass is a common presenting sign of breast cancer. Imaging evaluation is necessary in almost all cases to characterize the palpable lesion. Recommended imaging options include diagnostic mammography and targeted breast ultrasound (US), and are dependent on patient age and degree of radiologic suspicion. Any highly suspicious mass detected by imaging or palpation should undergo image-guided core biopsy (US guided, stereotactic, or digital breast tomosynthesis guided) unless contraindicated.

Diagnostic Mammography and Digital Breast Tomosynthesis

Diagnostic mammography (DM) is indicated for women age 30 and over who are presenting with a palpable lump. If a clearly benign correlate for a palpable finding (oil cyst, lipoma, etc.) can be identified on DM, this modality alone may be sufficient, and clinical follow-up would be appropriate. If DM is negative or an imaging correlate is identified that is not clearly benign, targeted ultrasound (US) directed to the palpable finding should be performed. Digital breast tomosynthesis is can improve address some of the limitations encountered with standard DM views. DM or digital breast tomosynthesis may also be helpful in women ages 30 to 39 with palpable lumps and in women younger than 30 with palpable lumps and suspicious findings on US.

Ultrasound

Ultrasound (US) is recommended as the first-line investigation for a palpable lump in women under age 30, and in pregnant and lactating women. In the event of a suspicious finding on ultrasound, digital Mammography is warranted even in younger women in order to better delineate disease and identify features of malignancy that may be seen on digital mammography alone. US is also an essential next step in evaluating women ≥30 years with a palpable mass and either a negative mammogram or a finding not unequivocally characterized as benign on mammogram.

Palpable Breast Lumps Summary Recommendations

  1. Women age 30 and over: DM initially, followed by targeted US.
    •  Suspicious or negative findings → US
    • Probably benign findings → US or mammography/digital breast tomosynthesis short interval follow-up
  2. Women age 30-39: DM and targeted US → next steps as above.
    • Suspicious findings → biopsy > DM

    • Probably benign findings → US or DM short term follow-up

  3. Women younger than 30, pregnant or lactating → US initially. Suspicious findings → biopsy > diagnostic mammography
    • Probably benign findings → US or DM short term follow-up
    • Negative findings → clinical follow up, DM or digital breast tomosynthesis rarely helpful
  4. Any highly suspicious breast mass detected by imaging should have core biopsy, whether or not it is a palpable finding.
  5. Any highly suspicious breast mass detected by palpation should be biopsied, irrespective of imaging findings.

 

Nonpalpable Mammographic Findings

breast icon

Screening mammography allows the detection of early, clinically occult cancers. Most lesions detected on screening mammograms are benign. Lesions that are concerning include masses, focal asymmetries, architectural distortions, and some types of calcifications. Diagnostic mammography (DM) and/or ultrasound (US) is necessary for further evaluation.

Ultrasound

Ultrasound (US) can be used to differentiate cystic from solid masses. Round or oval masses can be further investigated with US for more characterization. US is not required for evaluation of suspicious or likely malignant mammographic findings. US can also evaluate architectural distortions found on mammography. Negative US evaluation of suspicious mammographic findings should not dissuade the decision to biopsy.

MRI

MRI evaluation of nonpalpable noncalcified mammographic lesions is controversial and should not be used when established methods can confidently evaluate a finding. 

Biopsy

Final assessment of mammographically detected suspicious lesions should be assigned according to the ACR Breast Imaging, Reporting and Data System (BI-RADS) Atlas. If a lesion is a BI-RADS category 4 or 5, a percutaneous core biopsy is warranted, with either mammographic or US guidance. Percutaneous biopsy should be done to shorten the diagnostic process and/or provide a more cost-effective method of diagnosis as compared with excisional biopsy. Percutaneous biopsy of suspicious lesions can provide accurate tissue diagnosis at decreased cost, precluding the need for surgery in specific benign cases and allowing definitive, single-stage surgical treatment in cases that are as malignant.

Nonpalpable Mammographic Summary Recommendations

  • Architectural distortion seen on screening mammogram  → DM, US as needed
  • Mass (indistinct, obscured or microlobulated margins) seen on screening mammogram DM and then US
  • Mass (circumscribed without suspicious features) seen on screening mammogram US (DM may also be needed)
  • Multiple bilateral nonsuspicious masses seen on screening mammogram  Return to screening mammography
  • Multiple bilateral masses seen on screening mammogram with dominant or suspicious mass DM and US
  • Focal asymmetry or asymmetry (single-view finding) seen on screening mammogram DM, possibly with US
  • Grouped calcifications DM with magnification views

 

Breast Pain

breast icon

Breast pain or tenderness occurs in 70 to 80 percent of women during their lifetime. It is not a common symptom of underlying malignancy. Breast imaging often provides reassurance if negative, but it may also lead to further clinical and imaging evaluation. Nevertheless, a persistent or focal area of pain or tenderness is an indication for imaging according to the American College of Radiology (ACR) practice guidelines. Imaging recommendations under these circumstances focus on non-high-risk patients assumed to have appropriate routine screening mammography according to the ACR guidelines.

Benign Causes

  • Hormonal medicines
  • Selective serotonin reuptake inhibitors
  • Psychological causes
  • Duct ectasia with periductal inflammation
  • Mastitis or breast abscess
  • Trauma
  • Surgery or implants
  • Pregnancy and breast-feeding
  • Thelarche
  • Nerve irritation
  • Musculoskeletal causes
  • Coronary, pulmonary, esophageal or gallbladder pathology

Breast Cancer Causes

  • Advanced breast cancer with significant tissue invasion
  • Invasive lobular carcinoma
  • Anaplastic carcinoma
  • Adenoid cystic carcinoma

Types of Breast Pain

Cyclical (most common, diffuse, unilateral or bilateral, third decade)—sensitivity to normal hormonal levels, these women undergo more frequent breast investigations

Noncyclical (25 percent, focal, unilateral, fourth decade)—inflammatory, may need evaluation to exclude malignancy

Breast Pain Summary Recommendations

  1. Women with cyclical and/or bilateral nonfocal pain or tenderness usually do not require nonroutine imaging.
  2. Women with noncyclical, unilateral or focal breast pain that is not extramammary in origin may benefit from imaging to exclude breast cancer, determine benign but treatable etiology, or to offer reassurance that there is no causative abnormality. Ultrasound is the first test used in symptomatic women < 30 years old, or pregnant or lactating women.
    • Diagnostic mammography (unilateral or bilateral) may be added to ultrasound in symptomatic women < 30 years old with suspicious ultrasound, at the radiologist’s discretion.
    • Digital Mammography and ultrasound in symptomatic women 30 and older, or in any patient qualifying for mammography, based on risk factors and the date of the last mammogram.
  3. There is no evidence to suggest that breast MRI or nuclear imaging (molecular breast imaging or positron emission mammography) meet risk/benefit or cost-effectiveness criteria to be used in the work-up of breast pain or tenderness.

 

Breast Imaging Codes:

Screening CodesIMG CodeCPT Code
Breast Digital Mammography Screening BilateralIMG807077069
Breast Digital Mammography Screening Bilateral w/ TOMO IMG807477063, 77067
Breast Digital Mammography Screening Left Post CancerIMG807177067
Breast Digital Mammography Screening Right Post CancerIMG807277067
Breast Digital Mammography Screening Left Post Cancer w/TOMOIMG807977063, 77067
Breast Digital Mammography Screening Right Post Cancer w/TOMOIMG807877063, 77067
Breast US Screening Bilateral CompleteIMG709976641
Diagnostic Mammogram CodesIMG CodeCPT Code
Breast Digital Mammography Diagnostic BilateralIMG803177066
Breast Digital Mammography Diagnostic RightIMG803277065
Breast Digital Mammography Diagnostic LeftIMG303377065
Breast Digital Mammography Diagnostic Bilateral w/ TOMO IMG60177062, 77066, G0279
Breast Digital Mammography Diagnostic Right w/ TOMO IMG60277061, 77065, G0279
Breast Digital Mammography Diagnostic Left w/TOMOIM60377061, 77065, G0279
Diagnostic Ultrasound CodesIMG CodeCPT Code
Breast US Bilateral LIMITEDIMG58176642
Breast US Left LIMITEDIMG58276642
Breast US Right LIMITEDIMG58376642
Breast US Bilateral COMPLETEIMG801276641
Breast US Left COMPLETEIMG807776641
Breast US Right COMPLETEIMG807676641
Breast US AxillaIMG801076882
Breast MRIIMG CodeCPT Code
MRI Breast Bilateral w/wo ContrastIMG114377049, C8908
MRI Breast Bilateral wo Contrast *Only for implants*IMG114477047
Breast BIOPSY CodesIMG CodeCPT Code
Breast US Biopsy CoreIMG106919083
Breast Stereotactic BiopsyIMG61419081
MRI Breast BiopsyIMG308419085
Breast US Fine Needle AspirationIMG423510005
Breast US Breast Cyst AspirationIMG800019000, 76942
Breast US Abscess DrainageIMG800919020, 76942
Breast Surgical CodesIMG CodeCPT Code
Breast Sentinel Node InjectionIMG802038792
Breast Localization w/ US GuidanceIMG800419285
Breast Digital Mammography Guided Needle LocalizationIMG801919281
Post Procedure CodesIMG CodeCPT Code
Breast Digital Mammography Diagnostic Bilateral Post ProcedureIMG499777066
Breast Digital Mammography Diagnostic Left Post ProcedureIMG499977065
Breast Digital Mammography Diagnostic Right Post ProcedureIMG499877065
Breast Digital Mammography Diagnostic Bilateral Post Procedure w/TOMOIMG255177062, 77066, G0279
Breast Digital Mammography Diagnostic Left Post Procedure w/TOMOIMG255277061, 77065, G0279
Breast Digital Mammography Diagnostic Right Post Procedure w/TOMOIMG255377061, 77065, G0279