The Breast Imaging Reporting and Data System (BI-RADS) is a comprehensive guideline to systematize breast imaging reporting, and as per its recommendations, any lesion with likelihoods of malignancy greater than 2% is deemed as suspicious and tissue diagnosis is recommended. The aim of the study is to determine the positive predictive value (PPV) of BI-RADS categories 4a, 4b, and 4c for malignancy and association of mammographic morphological features of BI-RADS 4 subgroups with malignant outcomes. We retrospectively reviewed all the patients undergoing mammography with BI-RADS score of 4 followed by biopsy from May 2019 to April 2020. The predictive values of BI-RADS 4 subcategories and morphological features with malignancy are performed taking histopathology report as the gold standard. The PPV of BI-RADS subcategories 4a, 4b, and 4c for malignancies were 34, 89, and 97%, respectively. BI-RADS 4c patients tend to be older (50.2 ± 12.2 vs. 44.6 ± 10.3 years) with larger mass (44 ± 16 vs. 32.9 ± 16.8 mm) at presentation than 4a. Postmenopausal state ( P = 0.03) and older age ( P = 0.019) were significantly associated with malignancy. There is no meaningful difference observed in the predictability of BI-RADS category 4c lesions among different breast density patterns. The overall higher PPV for BI-RADS 4a and 4b reflects subjectivity in subcategory assignments of BI-RADS 4. In patients, less than 40 years with the BI-RADS 4a category on mammograms may undergo supplementary imaging with MRI which may downscale the lesion classification in turn reducing unnecessary biopsy and surgery.