Cleft hard palate

This diagnosis code signifies a congenital malformation characterized by an opening or split in the bony roof of the mouth, separating the oral cavity from the nasal cavity. This defect can range in severity from a small notch to a complete separation extending from the front to the back of the hard palate. It often impacts feeding, speech development, and dental alignment.

Assign this code when documentation clearly indicates a patient has a congenital cleft involving only the hard palate. This code is appropriate for initial diagnosis, during surgical repair, and for follow-up care related to this specific anatomical defect. Supporting documentation includes physician notes, surgical reports, and imaging studies confirming the location of the cleft.

• Do not use this code if the cleft also involves the soft palate or lip; more specific combination codes exist.
• Always review documentation to determine if the cleft is unilateral or bilateral, as this may impact other associated codes.
• Consider sequencing this code as the primary diagnosis when it is the main reason for the encounter, especially for surgical repair.