Cleft hard palate with cleft soft palate

This diagnosis code signifies a congenital malformation involving a complete cleft of both the hard and soft palates. This condition results in an opening between the oral and nasal cavities, affecting speech, feeding, and often leading to recurrent ear infections. It is a more extensive form of palatal clefting compared to isolated hard or soft palate involvement.

Assign this code when documentation explicitly states a "cleft hard and soft palate" or "complete cleft palate." This code is appropriate for initial evaluations, surgical repairs, and ongoing management of patients with this specific congenital anomaly. Supporting documentation should clearly identify the involvement of both the hard and soft palates.

• Do not use this code if only the hard palate or only the soft palate is affected; specific codes exist for those isolated conditions.
• Consider additional codes for associated conditions, such as cleft lip (Q36.-) if present, or other congenital anomalies.
• Proper sequencing may be required if this is a secondary diagnosis related to another primary condition or procedure.