Cervical Screening Programme
Department of Health
The Government of the Hong Kong Special Administrative Region

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(i) The Bethesda 2001 System

(ii) SNOMED

 

(i) The Bethesda 2001 System
1. Specimen type
Conventional smear (Pap smear) vs liquid-based vs others
2. Specimen adequacy
1. Satisfactory for evaluation
2. Unsatisfactory for evaluation e.g. unlabelled specimen, broken slide, inadequate cellularity, absent transformation zone, excessive obscuring factors
3. General categorization (optional)
1. Negative for intraepithelial lesion or malignancy
2. Epithelia cell abnormality
3. Other
4. Automated review
Specify automated device and result, if used
5. Ancillary testing

Brief description of test methods and result

6. Interpretation / result
1.

Negative for intraepithelial lesion or malignancy: (state if the following findings exist)
- Organisms e.g. Trichomonas, Candida, HSV
-

Non-neoplastic findings e.g. reactive changes, glandular cells status post-hysterectomy, atrophy

2.

Epithelia cell abnormality:
- Squamous cell:
Atypical squamous cells (ASC),
Low-grade squamous intraepithelial lesion (LSIL),
High-grade intraepithelial lesion (HSIL),
Squamous cell carcinoma (SCC),
-

Glandular cell:
Atypical glandular cells (AGC),
Adenocarcinoma in situ (AIS)

3. Other: endometrial cells in a woman >= 40 years old
7. Education notes and suggestions (optional)

(ii) SNOMED

SNOMED for histology coding

The Cervical Screening Task Force recommended a uniform reporting system for histology coding of cervical biopsies, preferably the SNOMED system.

SNOMED stands for Systematized Nomenclature of Medicine, which was developed by a division of the College of American Pathologists. The aim is to provide a system of dynamic and sustainable, scientifically validated terminology and infrastructure that enables clinicians, researchers and patients to share health care knowledge worldwide, across clinical specialties and sites of care.

The followings are some examples of coding for diseases and disorders of female genital system:

M-80703 Carcinoma, squamous cell, NOS
M-80702 Carcinoma, squamous cell, in-situ, NOS (CIN III)
M-80713 Carcinoma, squamous cell, keratinizing type
M-80723 Carcinoma, squamous cell, large cell, non-keratinizing type
   
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