2025 ICD-10-CM code Q36.9
(Active) Effective Date: N/A Congenital malformations, deformations and chromosomal abnormalities - Cleft lip and cleft palate Q00-Q99 Feed
Cleft lip, unilateral. Cleft lip NOS.
Medical necessity for repair is established by the presence of the cleft lip, which impairs feeding, speech development, and potentially psychological well-being.
Diagnosis and management often involves a multidisciplinary team including pediatricians, plastic surgeons, oral and maxillofacial surgeons, geneticists, speech therapists, and dentists.
In simple words: A birth defect where a baby's upper lip doesn't fully close during pregnancy, causing a split on one side.
A congenital split in the upper lip on one side, which can range from a small notch to a complete separation extending into the nose.It's also known as cheiloschisis, congenital fissure of lip, harelip, or labium leporinum.
Example 1: A newborn is observed with a complete split in the left upper lip extending into the nose, classified as a unilateral complete cleft lip (Q36.9)., An infant presents with a minor notch in the right upper lip, barely affecting the vermillion border, diagnosed as a microform unilateral cleft lip (Q36.9)., A fetus is diagnosed prenatally with a split in the upper lip on one side during an ultrasound, documented as a unilateral cleft lip (Q36.9).
Type and extent of cleft (complete/incomplete, microform), laterality (left/right), involvement of the nose/alveolus/palate, any associated syndromes or other birth defects.
- Specialties:Plastic Surgery, Pediatrics, Oral and Maxillofacial Surgery, Genetics
- Place of Service:Inpatient Hospital, On Campus-Outpatient Hospital, Office