Cleft soft palate

This code represents a congenital malformation characterized by a fissure or opening in the muscular and membranous posterior part of the palate, which separates the oral cavity from the nasal cavity. This condition can affect speech, feeding, and ear health due to impaired function of the palatal muscles.

Use this code when documentation clearly indicates a diagnosis of a cleft involving only the soft palate, without involvement of the hard palate or lip. This is typically diagnosed at birth or shortly thereafter during a physical examination. Supporting documentation would include physician notes detailing the specific anatomical location of the cleft.

• Differentiate carefully from cleft hard palate (Q35.1) or complete cleft palate (Q35.5).
• Do not use this code if the cleft involves the lip; refer to codes in the Q36.- or Q37.- series.
• Consider additional codes for associated conditions such as feeding difficulties (e.g., R63.3) or speech impediments (e.g., R47.01).