Unspecified cleft palate with unilateral cleft lip
ICD-10 Q37.9 is a billable code used to indicate a diagnosis of unspecified cleft palate with unilateral cleft lip.
Unspecified cleft palate with unilateral cleft lip is a congenital malformation characterized by an opening in the roof of the mouth (palate) and a split in the upper lip on one side. This condition can vary in severity and may affect feeding, speech development, and dental health. The cleft palate occurs when the tissue that forms the palate does not fully come together during fetal development, leading to a gap that can extend into the nasal cavity. The unilateral cleft lip is a result of similar developmental disruptions, where one side of the lip fails to fuse properly. These conditions can occur in isolation or as part of a syndrome involving other congenital anomalies, including those affecting the respiratory system such as choanal atresia, tracheoesophageal fistula, and lung hypoplasia. Early diagnosis and intervention are crucial for managing feeding difficulties and preventing complications. Surgical repair is typically performed within the first year of life, and ongoing multidisciplinary care is often required to address speech therapy, orthodontics, and psychosocial support.
Detailed records of growth, feeding issues, and developmental assessments are essential. Documentation should include any surgical interventions and follow-up care.
A newborn with a unilateral cleft lip and palate presenting with feeding difficulties; a child requiring speech therapy due to cleft-related speech issues.
Consider the need for coordination with surgical teams and speech therapists to ensure comprehensive care and accurate coding.
Genetic counseling notes, family history, and any genetic testing results should be documented to assess for syndromic associations.
A child with cleft palate and additional congenital anomalies undergoing genetic evaluation; a family seeking genetic counseling due to a history of cleft conditions.
Document any syndromic associations and genetic testing results that may influence management and coding.
Used during surgical intervention for cleft lip repair.
Operative reports detailing the procedure and any complications.
Pediatric surgical documentation must include pre-operative assessments and post-operative follow-up.
Q37.9 refers to unspecified cleft palate with unilateral cleft lip, while Q37.0 specifically denotes unilateral cleft lip without a specified palate involvement. Accurate coding requires understanding the specific nature of the cleft.
