Cleft soft palate
ICD-10 Q35.3 is a billable code used to indicate a diagnosis of cleft soft palate.
Cleft soft palate is a congenital malformation characterized by an opening or gap in the soft tissue at the back of the roof of the mouth (palate). This condition can occur as an isolated defect or in conjunction with other congenital anomalies, such as cleft lip or other craniofacial abnormalities. The cleft can affect feeding, speech development, and may lead to recurrent ear infections due to Eustachian tube dysfunction. In pediatric patients, early diagnosis and intervention are crucial for optimal outcomes. Surgical repair is typically performed within the first year of life, and multidisciplinary care involving pediatricians, speech therapists, and otolaryngologists is often necessary to address the various challenges associated with this condition. Additionally, cleft soft palate may be associated with other congenital malformations, including respiratory system anomalies such as choanal atresia, tracheoesophageal fistula, and lung hypoplasia, which can complicate the clinical picture and require careful management.
Documentation should include details of the cleft's impact on feeding, growth, and development, as well as any associated respiratory issues.
Common scenarios include newborns with feeding difficulties, recurrent otitis media, and speech delays requiring intervention.
Coders should be aware of the need for ongoing assessments and interventions, including speech therapy and ENT evaluations.
Genetic counseling notes should document any syndromic associations and family history of congenital conditions.
Scenarios may include genetic testing for syndromes associated with cleft palate, such as 22q11.2 deletion syndrome.
Consideration of chromosomal abnormalities and syndromic presentations is crucial for accurate coding.
Used for surgical repair of cleft soft palate.
Document the indication for surgery and any pre-operative assessments.
Pediatric surgeons should provide detailed operative notes.
Common associated conditions include choanal atresia, tracheoesophageal fistula, and lung hypoplasia, which can complicate the clinical management of patients with cleft soft palate.
