Cleft lip
Chapter 17:Congenital malformations and chromosomal abnormalities
ICD-10 Q36 is a billable code used to indicate a diagnosis of cleft lip.
Cleft lip is a congenital malformation characterized by an opening or gap in the upper lip that can occur on one or both sides of the lip. This condition arises during early fetal development when the tissues that form the lip do not fully come together. Cleft lip can occur in isolation or in conjunction with a cleft palate, which is a similar defect affecting the roof of the mouth. The severity of cleft lip can vary significantly, ranging from a small notch in the lip to a large gap that extends up into the nose. This condition can lead to various complications, including difficulties with feeding, speech, and dental issues. Surgical intervention is typically required to repair the cleft and improve function and appearance. The timing of surgery often depends on the severity of the cleft and the overall health of the infant. Genetic factors may play a role in the occurrence of cleft lip, and it is often associated with other congenital anomalies, particularly those affecting the respiratory system, such as choanal atresia and tracheoesophageal fistula.
Documentation should include details of the cleft's severity, associated conditions, and any surgical interventions performed.
Infants presenting with feeding difficulties, speech delays, or requiring surgical repair.
Coders must be aware of the potential for multiple surgeries and the need for ongoing follow-up care.
Genetic testing results, family history of congenital anomalies, and any syndromic associations should be documented.
Cases where cleft lip is part of a genetic syndrome or when genetic counseling is provided.
Consideration of chromosomal abnormalities that may be associated with cleft lip, such as 22q11.2 deletion syndrome.
Used during surgical repair of cleft lip in infants.
Operative report detailing the procedure and any complications.
Pediatric surgical documentation must include pre-operative assessments.
Cleft lip refers to a gap in the upper lip, while cleft palate involves a gap in the roof of the mouth. They can occur together or separately.
