Cleft Lip and Cleft Palate ICD-10-CM codes

Three categories cover orofacial clefts. Q35 is cleft palate without cleft lip: Q35.1 hard palate, Q35.3 soft palate, Q35.5 hard and soft palate, Q35.7 cleft uvula, Q35.9 unspecified. Q36 is cleft lip without cleft palate: Q36.0 bilateral, Q36.1 median, Q36.9 unilateral, which is also the default for cleft lip not otherwise specified.

When both lip and palate are cleft, use a single combination code from Q37 rather than a Q35 code plus a Q36 code. The fourth character combines the part of the palate with the laterality of the lip: Q37.0 hard palate with bilateral cleft lip, Q37.1 hard palate with unilateral cleft lip, Q37.2 and Q37.3 soft palate with bilateral and unilateral cleft lip, Q37.4 and Q37.5 hard and soft palate with bilateral and unilateral cleft lip, and Q37.8 and Q37.9 unspecified cleft palate with bilateral and unilateral cleft lip.

Encounters for staged repair keep the Q code because the malformation is still present. Once the cleft has been fully corrected, report Z87.730 (personal history of corrected cleft lip and palate) for later encounters where the history is relevant. Feeding difficulty or speech problems related to the cleft are coded in addition when documented.