Cleft hard and soft palate with bilateral cleft lip
ICD-10 Q37.4 is a billable code used to indicate a diagnosis of cleft hard and soft palate with bilateral cleft lip.
Cleft hard and soft palate with bilateral cleft lip is a congenital malformation characterized by a split or opening in the upper lip and the roof of the mouth (palate) that occurs on both sides. This condition arises during early fetal development when the tissues that form the lip and palate do not fully come together. The severity of the cleft can vary, affecting feeding, speech, and dental health. Associated complications may include difficulties in breathing, especially if there are concurrent congenital malformations of the respiratory system such as choanal atresia or tracheoesophageal fistula. Children with this condition may also experience lung hypoplasia due to associated anomalies. Early intervention, including surgical repair and multidisciplinary care, is crucial for optimal outcomes. The management of these patients often involves a team of specialists, including pediatricians, surgeons, speech therapists, and genetic counselors, to address the multifaceted challenges presented by this condition.
Documentation must include details of the cleft's severity, associated anomalies, and treatment plans.
Management of feeding difficulties, speech therapy referrals, and surgical planning.
Consideration of growth and developmental milestones in children with cleft conditions.
Genetic counseling notes, family history, and any chromosomal studies performed.
Assessment for syndromic associations and genetic testing for chromosomal abnormalities.
Understanding the genetic basis of clefting and its implications for family planning.
Used during surgical intervention for cleft lip and palate repair.
Operative report detailing the procedure and any complications.
Pediatric surgical notes must include pre-operative assessments.
Common associated conditions include choanal atresia, tracheoesophageal fistula, and lung hypoplasia, which can complicate the management of patients with cleft hard and soft palate with bilateral cleft lip.
