Start New EnglishEspañol中文РусскийالعربيةTiếng ViệtFrançaisDeutsch한국어Tagalog Library Performance
BETA v.3.0

2025 ICD-10-CM code Q36.0

Bilateral complete cleft lip.A fissure of the upper lip that is present on both sides and may extend up to the nostril.

Use additional code to identify associated malformation of the nose (Q30.2). Do not use on maternal records. Excludes2: inborn errors of metabolism (E70-E88) and Robin's syndrome (Q87.0)

Medical necessity for treatment of bilateral cleft lip is generally established by the diagnosis itself.Surgical repair is necessary for restoring normal lip function, facilitating feeding, and addressing cosmetic concerns.

Diagnosis and management of this condition typically involves a multidisciplinary team, including pediatricians, plastic surgeons, geneticists, speech therapists, and dentists. Clinical responsibilities include assessment of the cleft's extent, genetic counseling, surgical repair, and long-term management of speech, hearing, and dental complications.

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.

** Only Enterprise users with EHR integration can access case-specific answers. Click here to request access.

Discover what matters.

iFrame™ AI's knowledge is aligned with and limited to the materials uploaded by users and should not be interpreted as medical, legal, or any other form of advice by iFrame™.