In simple words: A bilateral cleft lip is a birth defect where a baby's upper lip has a split on both sides.It can range from a small notch to a complete separation extending up to the nose. Sometimes it affects the gums as well.

A complete bilateral fissure of the upper lip, potentially extending to the nostril. This condition may also involve the gums or other structures. It represents a congenital malformation where the lip tissues on both sides fail to fuse properly during development.

Example 1: A newborn is diagnosed with a complete bilateral cleft lip extending into the alveolar ridge. ICD-10-CM code Q36.0 is used., A fetus is diagnosed prenatally with a bilateral cleft lip through ultrasound. This would be coded as Q36.0 after birth confirmation., An infant with a bilateral cleft lip also presents with a cleft palate. While Q36.0 describes the lip, an additional code from the Q37 series would be required to fully capture the cleft palate.

Documentation should clearly describe the extent and laterality of the cleft lip (complete/incomplete, bilateral). Any associated features such as alveolar ridge involvement or nasal deformity should be noted. Prenatal diagnoses should be confirmed postnatally.