Cleft lip and cleft palate
ICD-10 Codes (13)
Q36Q36.0Q36.1Q36.9Q37Q37.0Q37.1Q37.2Q37.3Q37.4Q37.5Q37.8Q37.9Updates & Changes
FY 2026 Updates
New Codes (1)
Revised Codes (1)
Deleted Codes
No codes deleted in this range for FY 2026
Historical Changes
- •FY 2025: Routine maintenance updates with minor terminology clarifications
- •FY 2024: Enhanced specificity requirements for certain code ranges
- •FY 2023: Updated documentation guidelines for improved clarity
Upcoming Changes
- •Proposed updates pending review by Coordination and Maintenance Committee
- •Under consideration: Enhanced digital health integration codes
Implementation Guidance
- •Review all FY 2026 updates for Q35-Q37 codes before implementation
- •Always verify the most current codes in the ICD-10-CM manual
- •Ensure clinical documentation supports the selected diagnosis codes
- +3 more guidance items...
Range Overview
The ICD-10 code range Q35-Q37 pertains to cleft lip and cleft palate, congenital anomalies affecting the upper lip and roof of the mouth. These codes are used to document various forms of these conditions, including unilateral, bilateral, complete, and incomplete clefts, with or without cleft palate. They also cover cleft palate with cleft lip and other and unspecified cleft palate.
Key Usage Points:
- •Q35.0 is used for Cleft palate with unilateral cleft lip.
- •Q35.1 is used for Cleft palate with bilateral cleft lip.
- •Q35.9 is used for Cleft palate with cleft lip, unspecified.
- •Q36.0 is used for Unilateral cleft lip.
- •Q36.9 is used for Cleft lip, unspecified.
- •Q37 codes are used for combinations of cleft lip and cleft palate.
Coding Guidelines
When to Use:
- ✓When a patient has a congenital cleft lip, regardless of its severity or laterality.
- ✓When a patient has a congenital cleft palate, regardless of its severity.
- ✓When a patient has both a cleft lip and cleft palate.
- ✓When a patient has a cleft condition, but the specific type is not documented.
- ✓When a patient has had surgery for cleft lip or palate and is in the postoperative period.
When NOT to Use:
- ✗When a patient has had a cleft lip or palate but it has been fully corrected.
- ✗When a patient has a non-congenital oral cavity defect.
- ✗When a patient has a cleft condition, but it is not of the lip or palate.
- ✗When a patient has a history of cleft lip or palate, but no current condition.
Code Exclusions
Always verify exclusions against the patient's medical record and the most recent version of the ICD-10-CM.
Documentation Requirements
Documentation for cleft lip and cleft palate should include the specific type of cleft, its severity, and its laterality if applicable. Any complications or associated conditions should also be documented.
Clinical Information:
- •Specific type of cleft (lip, palate, or both)
- •Severity of the cleft
- •Laterality of the cleft (if applicable)
- •Presence of any complications or associated conditions
- •Status of any surgical correction
Supporting Evidence:
- •Clinical notes from physical examination
- •Imaging reports
- •Surgical reports
- •Genetic testing results (if applicable)
Good Documentation Example:
Patient has a severe bilateral cleft lip and a complete cleft palate. Surgery is planned for next month.
Poor Documentation Example:
Patient has a cleft.
Common Documentation Errors:
- ⚠Not specifying the type of cleft
- ⚠Not documenting the severity of the cleft
- ⚠Not documenting the laterality of the cleft
- ⚠Not documenting any associated conditions or complications
Range Statistics
Coding Complexity
Coding for cleft lip and cleft palate can be moderately complex due to the need to accurately identify and document the specific type, severity, and laterality of the cleft, as well as any associated conditions or complications. Additionally, the status of any surgical correction must be documented.
Key Factors:
- ▸Determining the specific type of cleft
- ▸Assessing the severity of the cleft
- ▸Identifying any associated conditions or complications
- ▸Documenting the status of any surgical correction
Specialty Focus
These codes are most commonly used in pediatrics, plastic surgery, and otolaryngology.
Primary Specialties:
Clinical Scenarios:
- • A newborn diagnosed with a unilateral cleft lip.
- • A child with a bilateral cleft lip and palate scheduled for surgery.
- • A teenager with a history of cleft palate presenting with recurrent ear infections.
- • A patient with an unspecified cleft condition.
Resources & References
Resources for coding cleft lip and cleft palate include the ICD-10-CM Official Guidelines for Coding and Reporting, the American Cleft Palate-Craniofacial Association, and the American Academy of Pediatrics.
Official Guidelines:
- ICD-10-CM Official Guidelines for Coding and Reporting
- American Cleft Palate-Craniofacial Association
- American Academy of Pediatrics
Clinical References:
- Cleft Lip and Palate: MedlinePlus
- Cleft Lip and Cleft Palate: Mayo Clinic
Educational Materials:
- ICD-10-CM Coding for Cleft Lip and Palate: AAPC
- Coding for Cleft Lip and Palate: AHIMA
Frequently Asked Questions
How do I code for a patient with both a cleft lip and a cleft palate?
Use a Q37 code for a patient with both a cleft lip and a cleft palate. The specific code will depend on the severity and laterality of the clefts.