In the USA, the use of the American College of Radiology Breast Imaging-Reporting and Data System (ACR BI-RADS) has served not only as a quality assurance tool and guide to standardizing breast imaging reports but has also improved communication between referring physicians, researchers, and patients. In fact, in the USA, the Mammography Quality Standards Act of 1997 requires that all mammograms be assigned a BI-RADS category based on the finding of most concern. In this manuscript, we aim to review the recommendations provided in the 4 ^th edition of the ACR BI-RADS for mammography, USG, and MRI. We also review the major controversies surrounding the use of ACR BI-RADS .