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2025 ICD-10-CM code Q37

Cleft palate with cleft lip. Includes cheilopalatoschisis.

Use additional code to identify associated malformation of the nose (Q30.2). Do not use codes from Chapter XVII on maternal records.

Medical necessity for treatment is established by the presence of the cleft, its impact on feeding, speech, and overall health.

Diagnosis and management often involve a multidisciplinary team including pediatricians, surgeons, speech therapists, and dentists.Surgical repair is typically performed, and long-term care focuses on addressing potential complications like speech and feeding difficulties.

In simple words: This code represents a birth defect where there's a split or opening in both the lip and the roof of the mouth.

Cleft palate with cleft lip. This condition involves a congenital split in both the palate (roof of the mouth) and the lip.It's a type of orofacial cleft.

Example 1: A newborn infant is diagnosed with a cleft lip and palate affecting both the hard and soft palate and the lip on one side., A child presents for follow-up care after surgical repair of a cleft lip and palate. The child is receiving speech therapy to address articulation issues., An adult patient with a history of unrepaired cleft lip and palate seeks consultation for potential surgical options.

Documentation should specify the type of cleft (hard palate, soft palate, lip involvement – unilateral or bilateral), extent of the cleft, and any associated malformations. Imaging studies may be included.

** Excludes2: Robin's syndrome (Q87.0) and inborn errors of metabolism (E70-E88). This code requires a 5th character to specify laterality and involvement of the hard and/or soft palate. For example: Q37.1 (Cleft hard palate with unilateral cleft lip).

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