1. Copyright © 2001 College of American Pathologists “I Can’t Find the Right SNOMED Code - What Should I Do ?” A Guide to :- – Searching for terms – Using modifiers and – Composing coded phrases Help

2. Copyright © 2001 College of American Pathologists Is the Term Really Missing? If you require a certain code, or term for your application and you can not find it in SNOMED, what should you do ? –Think of other words that can be used to express the same idea? Search again based on these words. ExampleExample –Check a medical dictionary –Contact your software developer. They may have access to a SNOMED update. Still can’t find it ?

3. Copyright © 2001 College of American Pathologists Is the Term Really Missing? Can the concept you are trying to express be created by adding a modifier to an existing concept. ExamplesExamples Can the concept be broken down into 2 or more concepts, with valid codes? Example - Two procedures in one sentence Example Examples - Single procedure expressed using multiple data fields in an application Examples

4. Copyright © 2001 College of American Pathologists Example - Search Using Different Words Can’t find “Lung Cancer” Try searching for “Lung Carcinoma”

5. Copyright © 2001 College of American Pathologists Example - Using Modifiers Some software systems allow the use of modifiers to refine the meaning of a concept. Software developers should consult with the SNOMED International organization to determine appropriate usage for modifiers. E.g., Routine mammography –Procedure : Mammography (P5-40010) –Modifiers : Routine (G-D220) Emergency major split thickness skin graft –Procedure : Split thickness skin graft (P1-40D14) –Modifiers : Emergency, Major (G-D209,G-A216)

6. Copyright © 2001 College of American Pathologists Example - Breaking Terms Down “Excision of burn with split thickness skin graft” The word “with” is often an indication that a term can be broken down into two separate codes. –Excisional debridement of burn (P1-403A1) –Split thickness skin graft (P1-40D14) Note - Some software systems only allow one SNOMED code to be used per data field. Speak to your software developer about modifying your system to meet your coding requirements.

7. Copyright © 2001 College of American Pathologists Example - Breaking Terms Down Some software systems provide data fields in their application that allow coded items to be broken down and refined in a logical and consistent fashion. E.g., Excision of cyst from femur Procedure : Excision of cyst from bone (P1-10331) Body Site : Femur (T-12710) Another example

8. Copyright © 2001 College of American Pathologists Example - Breaking Terms Down E.g., Open drainage of cyst of pancreas Procedure : Incision and drainage (P0-02032) Body Site : Pancreas (T-65000) Morphology :Cyst (M-3340A) Approach : Open Approach (G-D057) Equipment : Another example

9. Copyright © 2001 College of American Pathologists Example - Breaking Terms Down E.g., Excision and debridement of first degree burn of the upper leg Procedure : Excisional debridement of burn (P1-403A1) Body Site : Above knee region (T-D9160) Morphology : First degree burn (M-11102) Approach : Equipment : Another example

10. Copyright © 2001 College of American Pathologists Example - Breaking Terms Down E.g., Laser removal of tattoo Procedure : Excision of tattoo of skin (P1-40316) Body Site : Morphology : Approach : Equipment : Laser device (A-23000)

11. Copyright © 2001 College of American Pathologists More Information contact us www.snomed.org