What are the ICD-10 Codes to Report Cleft Lip and Cleft Palate?

by | Last updated Mar 1, 2023 | Published on Aug 2, 2022 | Medical Coding

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One of the most common birth defects, cleft lip and cleft palate occur when the facial structures of an unborn baby do not form properly during pregnancy. Also called “orofacial clefts, these defects involve openings or splits in the upper lip, the roof of the mouth (palate) or both. Billing and coding for this genetic facial disorder can be complex as there are several codes and guidelines. Otolaryngologists treating children with this facial disorder must use the correct diagnosis and procedure codes on their medical claims. Most otolaryngologists rely medical billing and coding companies for accurate clinical documentation.

The exact cause of this facial malformation in many babies is not known. However, researchers believe that the condition is caused by an interaction of genetic, environmental and lifestyle factors (like diabetes, obesity during pregnancy, smoking and use of certain medications). In most cases, this problem of cleft lip and cleft palate can be corrected. Treatment for this condition involves a combination of surgery, speech therapy and dental work. Treatment modalities aim to provide a natural facial appearance to the child and improve their individual ability to speak, hear and eat normally. In most babies, surgeries help restore normal function and create a more normal appearance with minimal scarring.

Per reports from the Centers for Disease Control and Prevention (CDC, 2020 statistics), about 1 in every 1,600 babies is born with cleft lip with cleft palate in the United States. It is estimated that males are twice likely to have cleft lip, cleft palate, or both as females. Females are more likely to have a cleft palate only.

Cleft lip and cleft palate occur when tissues in the baby’s face and mouth don’t fuse properly. In normal cases, the tissues that make up the lip and palate fuse together in the second and third months of pregnancy. In babies with cleft lip and cleft palate, the fusion never takes place or occurs only part way, leaving an opening (cleft).

Babies can be born with a cleft lip, a cleft palate, or both. A cleft lip may just affect one side of the lip or there may be 2 clefts. It can range from a small notch to a wide gap (that reaches the nose). Cleft palate, on the other hand, may involve an opening at the back of the mouth or a split in the palate (that runs all the way to the front of the mouth). If left untreated, the facial problem can lead to several complications like – difficulty feeding, hearing problems, dental problems and speech problems.

Symptoms That Cause Cleft Lip and Cleft Palate

Generally, a split (cleft) in the lip or palate is immediately identifiable at birth. On the other hand, a cleft that occurs only in the muscles of the soft palate at the back of the mouth, covered by the mouth’s lining often goes unnoticed at birth. In fact, this may not be diagnosed until later when signs develop. Symptoms associated with this facial disorder include –

  • Chronic ear infections
  • Nasal speaking voice
  • Difficulty with feedings
  • Difficulty swallowing (with potential for liquids or foods to come out the nose)

Diagnosis, Treatment and ICD-10 Codes

In most cases, cleft lip and cleft palate (or both) can be easily identified at birth during the initial examination and do not require any special tests for diagnosis. However, a pre-natal ultrasound scan can properly spot facial clefts from around the 13th week of pregnancy. When analyzing the images of the changing or developing fetus, physicians can detect anomalies in the facial structure or features. As the fetus develops, diagnosing a cleft lip becomes easier. However, cleft palate that occurs alone is more difficult to view on ultrasound. If the image in a prenatal ultrasound shows a cleft, physicians may suggest performing an amniotic fluid test, where a sample of amniotic fluid from the uterus (amniocentesis) may be collected for diagnosis. The fluid test could help indicate whether the fetus has inherited a genetic syndrome that may potentially cause any other birth defects. However, in most cases, the cause of cleft lip and cleft palate is unknown.

Treatment for cleft lip and cleft palate aims to restore a normal facial appearance and improve the child’s ability to eat, speak and hear normally. A team of specialists involving – surgeons who specialize in cleft repair, such as plastic surgeons or ENTs (also called Otolaryngologists), pediatricians, pediatric dentists, orthodontists, hearing specialists, speech therapists and genetic counselors are involved in the diagnosis and treatment activities. Treatment involves surgery to repair the birth defect and other therapies to improve any related conditions. Common surgical techniques include cleft lip repair, cleft palate repair, ear tube surgery and additional procedures to reconstruct or improve the appearance of the mouth, lip and nose.

While documenting diagnosis and treatment, otolaryngologists must report the correct medical codes. Medical billing services provided by reputable companies can help physicians report the correct codes for billing purposes.

ICD-10 Codes Used to Report Cleft lip and Cleft palate include –

  • Q35 Cleft palate
    • Q35.1 Cleft hard palate
    • Q35.3 Cleft soft palate
    • Q35.5 Cleft hard palate with cleft soft palate
    • Q35.7 Cleft uvula
    • Q35.9 Cleft palate, unspecified
  • Q36 Cleft lip
    • Q36.0 Cleft lip, bilateral
    • Q36.1 Cleft lip, median
    • Q36.9 Cleft lip, unilateral
  • Q37 Cleft palate with cleft lip
    • Q37.0 Cleft hard palate with bilateral cleft lip
    • Q37.1 Cleft hard palate with unilateral cleft lip
    • Q37.2 Cleft soft palate with bilateral cleft lip
    • Q37.3 Cleft soft palate with unilateral cleft lip
    • Q37.4 Cleft hard and soft palate with bilateral cleft lip
    • Q37.5 Cleft hard and soft palate with unilateral cleft lip
    • Q37.8 Unspecified cleft palate with bilateral cleft lip
    • Q37.9 Unspecified cleft palate with unilateral cleft lip

Though cleft lip and cleft palate cannot be prevented, following certain steps like – taking prenatal vitamins, undergoing genetic counseling (for those have a family history of cleft lip and cleft palate) and quitting tobacco and alcohol during pregnancy can help prevent or reduce the risk of these conditions.

Medical billing and coding for otolaryngology conditions can be complex. For accurate and timely medical billing and claims submission, healthcare practices can outsource their medical coding tasks to a professional otolaryngology medical billing company that provides the services of experienced AAPC-certified coders.

Loralee Kapp

Since joining our RCM Division in October 2021, Loralee, who is HIT Certified (Health Information Technology/Health Information Management), brings her extensive expertise in medical coding and Health Information Management practices to OSI.

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