2025 ICD-10-CM code Q35.9
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Congenital malformations - Cleft lip and cleft palate XVII: Congenital malformations, deformations and chromosomal abnormalities Feed
Unspecified cleft palate.
The medical necessity is established by the presence of a cleft palate, requiring evaluation, diagnosis, and potential treatment.Documentation should support the need for further evaluation or intervention.
Diagnosis and possible treatment planning for a cleft palate.
- XVII: Congenital malformations, deformations and chromosomal abnormalities
- Q35-Q37: Cleft lip and cleft palate
In simple words: This code means a cleft palate, a split in the roof of the mouth, where the details of the split are not known or described by the doctor.
This ICD-10-CM code, Q35.9, signifies an unspecified cleft palate.It is used when a cleft palate is present, but the specific type (hard, soft, or both) or location is unknown or not specified in the medical documentation.This code is included within the broader category of cleft lip and cleft palate (Q35-Q37).Additional codes may be used to identify any associated malformations of the nose (Q30.2).This code excludes Robin's syndrome (Q87.0).
Example 1: A newborn infant is examined, and a cleft palate is noted.Further investigation is required to determine the exact type and extent of the cleft before assigning a more specific code.Q35.9 is assigned pending further information., A patient presents with a history of a cleft palate repair in early childhood.The exact type of cleft is not documented in the available records, leading to the use of Q35.9., A medical record describes a palatal fissure without additional details regarding the location or extent.In the absence of more precise information, Q35.9 is the appropriate code.
Complete clinical notes describing the presence of a cleft palate.If possible, specify the location (hard, soft, or both) and extent of the cleft.Images or other supporting documentation may be necessary for complete clinical documentation.
** This code should only be used when the specific type or location of the cleft palate is unknown or cannot be determined from the available documentation.Always review the entire medical record to ensure the most accurate coding.
- Payment Status: Active
- Specialties:Plastic Surgery, Oral and Maxillofacial Surgery, Pediatrics
- Place of Service:Office, Hospital, Birth Center