CM-933 Roentgenographic Interpretation

U.S. Department of Labor

Roentgenographic Interpretation

Employment Standards Administration
Office of Workers' Compensation Programs
Division of Coal Mine Workers' Compensation
NOTE: This report is authorized by law (30 U.S.C., 901 et. seq.) and required to obtain a benefit. The results of this
interpretation will aid in determining the miner's eligibility for black lung benefits. Disclosure of a social security number is
voluntary. The failure to disclose such number will not result in the denial of any right, benefit, or privilege to which the
claimant may be entitled. This method of collecting information complies with the Freedom of information Act, the Privacy
Act of 1974, and OMB Cir. No. 108.

OMB No. 1215-0090
Expires: 07-31-2008

Please record your interpretation of a single film by placing "X" in the appropriate boxes on the form and return it promptly to the office that
requested the interpretation. The form must be completed as per instructions, signed by a physician, and contain the miner's name, and
social security number. The Department of Labor will pay only for films of acceptable quality (1, 2 and 3). Films of inferior quality (U/R) must
be retaken without cost to the Department.
1A. Date of X-ray

1. Miner's Name (Print)

1B. Miner's Social Security Number

1C. Film Quality (If not Grade
1. Give Reason):
1

Mo.

Day

NO

Proceed to Section 5

Complete Section 2A

2B. Small Opacities Consistent With Pneumoconiosis
a. SHAPE/SIZE
PRIMARY
SECONDARY
p

s

p

s

q

t

q

t

r

U

r

U

U/R

3

2A. Any Parenchymal Abnormalities Consistent with Pneumoconiosis?

1D. Is Film Completely Negative?
YES

2

Yr.
YES

0/__

0/0

0/1

1/0

1/1

1/2

2/1

2/2

2/3
SIZE

3/2

Proceed to Section 3

2C. Large Opacities Consistent With Pneumoconiosis

c. PROFUSION

b. ZONES

NO

Complete 2B and 2C

0

A

B

Proceed to
Section 3

C

3/+

3/3

R L
3A. ANY PLEURAL ABNORMALITIES
CONSISTENT WITH PNEUMOCONIOSIS?
3B. PLEURAL PLAQUES

(mark site, calcification, extent, and width))

Site

Chest wall

Extent (chest wall; combined for
in profile and face on)
Up to 1/4 of lateral chest wall = 1
1/4 to 1/2 of lateral chest wall = 2
> 1/2 of lateral chest wall = 3

Calcification

In Profile

O

R

L

O

R

L

Face On

O

R

L

O

R

L

Diaphragm

O

R

L

O

R

L

O

R

Other site(s)

O

R

L

O

R

L

1

2

3C. COSTOPHRENIC ANGLE OBLITERATION

R

L

Site

3

O

L

1

2

Calcification

3

O

R

a

b

Proceed to
Section 3D

In Profile

O

R

L

O

R

L

O

R

Face On

O

R

L

O

R

L

1

2

4A. ANY OTHER ABNORMALITIES?

c

O

L

1

2

3

O

L

a

b

c

Proceed to
Section 4A

NO

Complete
4B and 4C

YES

Proceed to
Section 4A

NO

Width (in profile only)
(3m minimum width required)
3 to 5 mm = a
5 to 10 mm = b
> 10 mm = c

Extent (chest wall; combined for
in profile and face on)
Up to 1/4 of lateral chest wall = 1
1/4 to 1/2 of lateral chest wall = 2
> 1/2 of lateral chest wall = 3

3D. DIFFUSE PLEURAL THICKENING (mark site, calcification, extent, and width))

Chest wall

Complete Sections
3B, 3C

YES

Width (in profile only)
(3m minimum width required)
3 to 5 mm = a
5 to 10 mm = b
> 10 mm = c

3

O

R

a

b

c

O

L

a

b

c

px

ra

rp

Proceed to
Section 5

NO

4B. OTHER SYMBOLS (OBLIGATORY)
aa

at

ax

bu

REPORT ITEMS WHICH
MAY BE OF PRESENT
CLINICAL SIGNIFICANCE
IN THIS SECTION.

ca

cg

cn

co

cp

cv

di

ef

em

es

(Specify od.)

fr

hi

ho

id

ih

kl

me pa

pb

pi

tb

Date Personal Physician notified?
Mo.

OD

Day

Yr.

4C. OTHER COMMENTS

SHOULD WORKER SEE PERSONAL PHYSICIAN BECAUSE OF COMMENTS IN SECTION 4C?

Yes No

Proceed to Section 5

5A. FACILITY PROVIDING ROENTGENOGRAPHIC EXAMINATION:
DOL Medical Provider Number (If applicable):
Was film taken by a registered radiographer/radiographic technologist?
Name

Yes

No

State

Registration No.

5B. Physician Interpreting Film (Print Name):
Are you: Board-certified Radiologist?

Yes

No.

Board-eligible radiologist?

Yes

No.

B-reader?

Yes

No.

5C. I certify that this film has been interpreted in accordance with the instructions provided on Form CM-954a and/or 20 CFR 718, Subpart B,
718.102 and Appendix A. I also certify that the information furnished is correct and am aware that my signature attests to the accuracy of
the results reported. I am aware that any person who willfully makes any false or misleading statements or representation in support of an
application for benefits under Title 30 USC 941 shall be guilty of a misdemeanor and subject to a fine of up to $1,000, or to imprisonment for
up to one year, or both.
PHYSICIAN'S SIGNATURE

DATE OF READING
(Mo., Day. Yr.)

Public Burden Statement
We estimate that it will take an average of 5 minutes to complete this information collection, including time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the information. If you have
any comments regarding these estimates or any other aspect of this survey, including suggestions for reducing this burden, send them to
the Division of Coal Mine Workers' Compensation, U.S. Department of Labor, Room N-3464, 200 Constitution Avenue, N.W., Washington,
D.C. 20210.
DO NOT SEND THE COMPLETED FORM TO THIS OFFICE
NOTE: Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number.
Form CM-933
Rev. Nov. 1996

For Purposes of Coding for the Department of Labor, the following criteria will be used
ILO 2000 INTERNATIONAL CLASSIFICATION OF RADIOGRAPHS OF THE PNEUMOCONIOSES
DEFINITIONS

CODES

FEATURES
Technical Quality

1
2

Parenchymal
Abnormalities
Small Opacities

4

Good.
Acceptable with no technical defect likely to impair classification of
the radiograph for pneumoconiosis.
Poor, with some technical defect but still acceptable for classification
purposes.
Unacceptable.
The category of profusion is based on the assessment of concentration
of opacities by comparison with the standard radiographs.

3
Profusion

Extent

0/- 0/0 0/1
1/0 1/1 1/2
2/1 2/2 2/3
3/2 3/3 3/+

Category 0 - small opacities absent or less profuse than the lower limit
of Category 1.
Categories 1, 2 and 3 - represent increasing profusion of small opacities
as defined by the corresponding standard radiographs.
The zones in which the opacities are seen are recorded. The right (R) and
left (L) thorax are both divided into three zones - upper (U), middle
(M) and lower (L).
The category of profusion is determined by considering the profusion
as a whole over the affected zones of the lung and by comparing this

RU RM RL
LU LM ILL

Shape and Size
rounded

with the standard radiographs.

The letters p, q and r denote the presence of small rounded opacities.
Three sizes are defined by the appearances on standard radiographs.

p/p q/q r/r

o = diameter up to about 1.5 mm.
q = diameter exceeding about 1.5 mm and up to about 3 mm.
r = diameter exceeding about 3 mm and up to about 10 mm.
Irregular

mixed

Lage Opacities

s/s t/t u/u

The letters s, t and u denote the presence of small irregular opacities.
Three sizes are defined by the appearance on standard radiographs.

p/s p/t
q/w q/t
r/s r/t
s/p s/q
t/p t/q
u/p u/q
ABC

s = width up to about 1.5 mm.
t = width exceeding about 1.5 mm and up to about 3 mm.
u = width exceeding 3 mm and up to about 10 mm.

p/u p/q p/r
q/u q/p q/r
r/u r/p r/q
s/r s/t s/u
t/r t/s t/u
u/r u/s u/t

For mixed shapes (or sizes) of small opacities the predominant shape
and size is recorded first. The presence of a significant number or
another shape and size is recorded after the oblique stroke.
The categories are defined in terms of dimensions of the opacities.
Category A - an opacity having a greatest diameter exceeding about 10
mm and up to and including 50 mm, or several opacities each greater
than about 10 mm, the sum of whose greatest diameters does not
exceed 50 mm.
Category B - one or more opacities larger or more numerous than
those In category A whose combined area does not exceed the
equivalent of the right upper zone.

Pleural Abnormalities
Pleural Thickening
Chest wall

Category C - one or more opacities whose combined area does not
exceeds the equivalent of the right upper zone.
Two types of pleural thickening of the chest wall are recognized:
circumscribed (plaques) and diffuse. Both types may occur together.

Type
Site
Width

L

Pleural thickening of the chest wall is recorded separately for the
right (R) and left (L) thorax.

ABC

For pleural thickening seen along the lateral chest wall the
measurement of maximum width is made from the inner line of the
chest wall to the inner margin of the shadow seen most sharply at the
parenchymal-pleural boundary. The maximum width usually occurs at the inner
margin of the rib shadow at its outermost point.

R

a = maximum width up to about 5 mm.
b = maximum width over about 5 mm and up to about 10 mm.
c = maximum width over about 10 mm.

Diaphragm
Costophrenic Angle

Face on

Y

N

The presence of pleural thickening seen face-on is recorded even if it
can be seen also in profile. If pleural thickening is seen face-on only,
width can not usually be measured.

Extent

1 2 3

Extent of pleural thickening is defined in terms of the maximum
length of pleural involvement or as the sum of maximum lengths,
whether seen in profile or face-on
1 -- total length equivalent up to one quarter of the projection of the
lateral chest wall.
2 - total length exceed one quarter but not one half of the projection
of the lateral chest wall.
3 - total length exceeding one half of the projection of the lateral chest
wall

Presence
Site
Presence

Site

Y
R
Y

R

N
L
N

A plaque involving the diaphragmatic pleura is recorded as present (Y)
or absent (N) separately for the right (R) or left (L) thorax.
The presence (Y) or absence (N) of costophrenic angle obliteration is
recorded separately from thickening over other areas for the right (R)
and left (L) thorax. The lower limit for the obliteration is defined by a
standard radiograph.

L

If the thickening extends up the chest wall then both costophrenic
angle obliteration and pleura thickening should be recorded.

Pleural calcification
Site
chest wall
diaphragm
other
extent

R
R
R
1

L
L
L
L
2

The site and extent of pleural calcification are recorded separately for
the two lungs, and the extent defined in terms of dimensions.
''Other'' includes calcification of the mediastinal and pericardial pleura.
1 = an area of calcified pleura with greatest diameter up to about 20
mm or a number of such areas the sum of whose greatest diameters
does not exceed about 20 mm.

3

2 = an area of calcified pleura with greatest diameter exceeding about
20 mm and up to about 100 mm or a number of such areas the
sum of whose greatest diameters exceeds about 20 mm but does not
exceed about 100 mm.
3 = an area of calcified pleura with greatest diameter exceeding about
100 mm or a number of such area whose sum of greatest diameters
exceeds about 100 mm.
It is to be taken that the definition of such of the symbols is preceded
by an appropriate word or phrase such as "suspect", "pneumoconiotic
changes suggestive of'', or ''opacities suggestive of'', etc.

Symbols

aa
aa
at
bu
ax
bu
ca
cg
cn
co
cp
cv
di
ef
em
es
fr

- atherosclerotic
- atheroscierotic
hi
- significant
apical pleural thickening
caof small pneumoconiotic opacities
- coalescence
cn
- bulla(e)
co
cp
- cancer of lung or pleura
cv
- calcified non-pneumoconiotic
di
ef
- calcification in small pneumcoconiotic opacities
em
es
- abnormality of cardiac size or shape
fr
- cor pulmonale
hi
ho
- cavity
id
- marked distortion of the intrathoracic organs
ih
kl
- effusion
od
- definite emphysema
pl
- eggshell calcification of hilar or mediastinalpxlymph nodes
rp
- fractured rib(s) (acute or healed)
tb

Comments

Presence

Y

N

hi
ho
id
ih
kl
me
pa
pb
pi
px
ra
rp
td
od

- enlargement
hilarpneumoconiotic
or mediastinal opacities
lymph nodes
- coalescence
of of
small
- bulla(e)
- honeycomb
lung
- cancer
of lung of
pleura
- calcification
in small pneumoconiotic opacities
- ill defined diaphragm
- abnormality of cardiac size of shape
- ill pulmonale
defined heart outline
- cor
- cavity
- septal (kerley) lines
- marked distortion of the intrathoracic organs
- mesothelioma
- effusion
- definite
- plateemphysema
atelactasis
- eggshell calcification of hilar or mediastinal lymph nodes
- parencymal
- fractured
rib(s) bands
- enlargement
of hilar of
or an
mediastinal
- pleural thickening
interiobarlumph
fissuenodes
- honeycomb lung
- ill- pneumothorax
defined diaphragm
- ill
defined heart
outline
- rounded
atelectasis
- septal (kerley) lines
- rheumatoid
- other
significantpneumoconiosis
abnormality
- pleural
thickening in the interiobar fissure or madiastinum
- tuberculosis
- pneurnathorax
- other significant
abnormality
- rtheumatoid
pneumoconiosis
- tuberculosis
Comments should be recorded pertaining to the classification of the
radiograph particularly if some other cause is thought to be responsible
for a shadow.