Cleft lip, unilateral
ICD-10 Q36.9 is a billable code used to indicate a diagnosis of cleft lip, unilateral.
Cleft lip, unilateral, is a congenital malformation characterized by a split or opening in the upper lip that occurs on one side. This condition arises during early fetal development when the tissues that form the lip do not fully come together. The severity of the cleft can vary, ranging from a small notch in the lip to a significant gap that extends up into the nose. Unilateral cleft lip can occur in isolation or in conjunction with other congenital anomalies, such as cleft palate. It is essential to assess the impact of this condition on feeding, speech development, and psychosocial aspects as the child grows. Surgical intervention is typically required to repair the cleft, and multidisciplinary care involving pediatricians, surgeons, speech therapists, and genetic counselors is crucial for optimal outcomes. The presence of associated congenital malformations, such as choanal atresia or tracheoesophageal fistula, may complicate the clinical picture and necessitate a comprehensive approach to management.
Detailed records of feeding difficulties, growth parameters, and developmental milestones are essential. Documentation should also include assessments of psychosocial impacts and referrals to specialists.
Common scenarios include newborns presenting with feeding difficulties due to cleft lip, children requiring speech therapy, and cases where surgical repair is planned.
Coders should be aware of the need for comprehensive documentation that captures the multidisciplinary approach to care, including input from speech therapists and nutritionists.
Genetic counseling notes should document family history, potential syndromic associations, and any genetic testing performed.
Scenarios may include families seeking genetic counseling after a diagnosis of cleft lip, particularly if there are concerns about recurrence in future pregnancies.
Coders should consider the implications of genetic syndromes that may present with cleft lip, such as Van der Woude syndrome or 22q11.2 deletion syndrome.
Used for surgical repair of unilateral cleft lip in infants.
Operative report detailing the procedure performed and any complications.
Pediatric surgeons should document the surgical approach and any associated procedures.
Unilateral cleft lip affects one side of the lip, while bilateral cleft lip involves both sides. The surgical approach and potential complications may differ significantly between the two.
