Cleft lip, median
ICD-10 Q36.1 is a billable code used to indicate a diagnosis of cleft lip, median.
Cleft lip, median, is a congenital malformation characterized by a fissure or opening in the upper lip that occurs in the midline. This condition arises during embryonic development when the left and right sides of the lip fail to fuse properly. Median cleft lip can occur in isolation or as part of a syndrome, such as holoprosencephaly, where there is incomplete separation of the cerebral hemispheres. The severity of the cleft can vary, affecting not only the cosmetic appearance but also the function of the lip, which may impact feeding and speech development in infants. Associated anomalies may include dental issues, nasal deformities, and in some cases, other congenital malformations such as choanal atresia or tracheoesophageal fistula. Early diagnosis and intervention are crucial for optimal outcomes, often involving a multidisciplinary team including pediatricians, surgeons, and speech therapists. Surgical repair is typically performed within the first year of life, and ongoing care may be necessary to address functional and aesthetic concerns.
Detailed records of feeding difficulties, growth parameters, and developmental milestones are essential. Documentation should include any associated respiratory or feeding issues.
Infants presenting with feeding difficulties due to cleft lip, referrals for surgical evaluation, and follow-up visits post-repair.
Coders should be aware of the need for ongoing assessments and potential additional procedures related to speech therapy and dental care.
Genetic counseling notes should document family history, potential syndromic associations, and any genetic testing results.
Cases where cleft lip is part of a genetic syndrome, such as Van der Woude syndrome, requiring genetic evaluation.
Consideration of chromosomal abnormalities and syndromic associations is crucial for accurate coding and management.
Used during surgical intervention for cleft lip repair.
Operative report detailing the procedure and any complications.
Pediatric surgeons should document the specifics of the repair technique used.
Cleft lip refers to a physical split or opening in the upper lip, while cleft palate refers to an opening in the roof of the mouth. Both conditions can occur together or separately and require different management strategies.
