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2025 ICD-10-CM code Q36

Cleft lip, a congenital fissure of the lip.

Follow the official ICD-10-CM coding guidelines when assigning this code.Consult the latest version of the manual for the most up-to-date information.

Modifiers may be applicable depending on the specific circumstances and the services provided.For example, modifiers might be necessary to indicate the type of anesthesia used or the place of service.

Surgical repair of a cleft lip is medically necessary to improve feeding, speech development, and facial aesthetics. The necessity is usually documented by a cleft palate specialist, plastic surgeon, or other qualified medical professional.

Diagnosis and potential surgical repair of the cleft lip.Post-operative care and management of any complications.

IMPORTANT:Use additional code Q30.2 to specify associated malformations of the nose.Excludes Q37 (cleft palate with cleft lip) and Q87.0 (Robin's syndrome).

In simple words: A cleft lip is a birth defect where there's a split or opening in the lip.It can be on one side (unilateral), both sides (bilateral), or in the middle of the lip.

Q36, Cleft lip, encompasses several presentations of a congenital fissure in the lip, including cheiloschisis, congenital fissure of the lip, harelip, and labium leporinum.This code excludes cases where the cleft involves both the lip and palate (coded as Q37).Specific sub-types, such as bilateral or unilateral cleft lip, may be further specified using additional digits.

Example 1: A newborn infant presents with a unilateral cleft lip on the left side.The diagnosis of Q36.9 is assigned. , A child with a bilateral cleft lip (Q36.0) undergoes surgical repair.The surgical procedure code(s) will be separately reported., A patient with a median cleft lip (Q36.1) requires both surgical intervention and speech therapy.The appropriate codes for both procedures are reported.

Complete prenatal history, physical examination findings, imaging studies (if any), surgical reports (if applicable), and documentation supporting the need for surgical or other interventions.

** The selection of the correct sub-type within Q36 depends on the location and extent of the cleft.Always refer to the official ICD-10-CM coding guidelines for proper coding practices.Additional codes may be required to document associated conditions or complications.

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