Cleft lip and cleft palate
ICD-10 Codes (0)
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Updates & 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 Q45-Q47 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 Q45-Q47 pertains to cleft lip and cleft palate, congenital malformations 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. They also cover associated anomalies and conditions such as cleft palate with cleft lip and cleft palate with cleft lip and cleft alveolus.
Key Usage Points:
- •Always specify the type of cleft (lip, palate, or both) and its severity (complete or incomplete).
- •Use additional codes to document any associated anomalies or conditions.
- •Remember that bilateral and unilateral clefts have different codes.
- •For recurrent clefts, use the appropriate code for the current condition and an additional code for the history of the cleft.
- •In case of multiple clefts, use separate codes for each.
Coding Guidelines
When to Use:
- ✓When a patient has a congenital cleft lip or palate.
- ✓When a patient has a cleft lip and palate together.
- ✓When a patient has a cleft lip or palate with associated anomalies.
- ✓When a patient has a history of cleft lip or palate that has been corrected but is relevant to current care.
- ✓When a patient has recurrent cleft lip or palate.
When NOT to Use:
- ✗When a patient has a non-congenital oral fissure or opening.
- ✗When a patient has a history of cleft lip or palate that is not relevant to current care.
- ✗When a patient has a cleft lip or palate that has not been confirmed by a physician.
- ✗When a patient has a cleft lip or palate that is being evaluated but not yet confirmed.
- ✗When a patient has an oral condition that is not a cleft lip or palate.
Code Exclusions
Always verify exclusions with the patient's medical record and the ICD-10 coding guidelines.
Documentation Requirements
Proper documentation for cleft lip and cleft palate should include a detailed description of the condition, its severity, and any associated anomalies or conditions. The type of cleft (lip, palate, or both) and its severity (complete or incomplete) should be clearly stated. Any history of the condition, including previous corrections, should also be documented.
Clinical Information:
- •Type of cleft (lip, palate, or both)
- •Severity of the cleft (complete or incomplete)
- •Presence of associated anomalies or conditions
- •History of the condition and any previous corrections
- •Current status of the condition
Supporting Evidence:
- •Medical history
- •Physical examination findings
- •Imaging studies
- •Surgical reports
Good Documentation Example:
Patient has a complete bilateral cleft lip and palate, with associated congenital heart defect. History of surgical correction of the cleft at 6 months of age.
Poor Documentation Example:
Patient has a cleft.
Common Documentation Errors:
- ⚠Not specifying the type and severity of the cleft
- ⚠Not documenting associated anomalies or conditions
- ⚠Not including a history of the condition and any previous corrections
- ⚠Not stating the current status of the condition
Range Statistics
Coding Complexity
The coding complexity for cleft lip and cleft palate is considered medium due to the need to accurately identify and code the type and severity of the cleft, any associated anomalies or conditions, and the history and current status of the condition. The variety of codes for different types and severities of clefts, as well as the need to apply the correct codes for recurrent or multiple clefts, adds to the complexity.
Key Factors:
- ▸Determining the type and severity of the cleft
- ▸Identifying and coding associated anomalies or conditions
- ▸Documenting the history and current status of the condition
- ▸Navigating the various codes for different types and severities of clefts
- ▸Applying the correct codes for recurrent or multiple clefts
Specialty Focus
These codes are primarily used by pediatricians, plastic surgeons, and otolaryngologists. They are also relevant to speech therapists, audiologists, and other healthcare providers involved in the care of patients with cleft lip and palate.
Primary Specialties:
Clinical Scenarios:
- • A newborn diagnosed with a unilateral incomplete cleft lip.
- • A toddler with a history of complete bilateral cleft lip and palate, presenting for follow-up after surgical correction.
- • A child with a complete cleft palate and associated congenital heart defect.
- • An adolescent with a history of cleft lip and palate, presenting with recurrent otitis media.
- • An adult with a history of cleft lip and palate, presenting for evaluation of speech difficulties.
Resources & References
Resources for coding cleft lip and cleft palate include the ICD-10 coding guidelines, clinical reference books and articles, and educational materials on congenital malformations and their management.
Official Guidelines:
- ICD-10-CM Official Guidelines for Coding and Reporting
- American Health Information Management Association (AHIMA) Coding Guidelines
- National Center for Health Statistics (NCHS) Coding Guidelines
Clinical References:
- American Cleft Palate-Craniofacial Association (ACPA) Clinical Standards
- American Academy of Pediatrics (AAP) Guidelines for Cleft Lip and Palate
- Plastic and Reconstructive Surgery Journal Articles on Cleft Lip and Palate
Educational Materials:
- AHIMA ICD-10 Training Modules
- ACPA Educational Resources
- AAP Patient Education Materials on Cleft Lip and Palate
Frequently Asked Questions
How do I code for a patient with a history of cleft lip and palate that has been corrected?
Use the appropriate code for the current condition (if any) and an additional code for the history of the cleft (Z87.59).