In simple words: This code describes a birth defect where the upper lip is split in the middle. This is a type of cleft lip that's different from those affecting only one side of the lip.

Q36.1, Cleft lip, median, is an ICD-10-CM code classifying a congenital fissure of the lip situated in the middle (median) of the upper lip.This condition is a birth defect resulting in an incomplete fusion of the lip during embryonic development.It's distinct from unilateral or bilateral cleft lips, which affect one or both sides of the lip, respectively. The code excludes cleft lip with cleft palate.

Example 1: A newborn infant is diagnosed with a median cleft lip during a routine physical examination. The physician documents the finding, and the code Q36.1 is used for billing and medical record keeping., A child presents with a median cleft lip, requiring surgical correction. The surgeon performs the cheiloplasty, documenting the procedure thoroughly. The code Q36.1 is used along with appropriate procedural codes to reflect the surgical intervention., An adult patient with a history of median cleft lip seeks consultation for aesthetic concerns. A plastic surgeon evaluates the patient and plans for reconstructive surgery. Code Q36.1 is used in the pre-operative and post-operative notes.

Complete medical history including prenatal history.Physical examination findings detailing the location and extent of the cleft.Imaging studies (if performed) such as ultrasound or photographs.Surgical reports for any corrective procedures.Post-operative care notes.Relevant consultation reports.

** This code is specific to a cleft lip in the midline.Careful differentiation from other types of cleft lip (unilateral, bilateral) and cleft lip with cleft palate is crucial for accurate coding.