Cleft uvula

This code identifies a congenital malformation characterized by a partial or complete division of the uvula, the small, fleshy projection hanging at the back of the soft palate. It represents a minor form of cleft palate, often presenting as a bifid uvula. This condition can sometimes be an isolated finding or associated with other congenital anomalies.

Assign this code when documentation specifies a cleft uvula, bifid uvula, or a split uvula. This diagnosis is typically made upon physical examination of the oral cavity, often during a routine check-up or evaluation for speech or feeding difficulties. Supporting documentation should clearly state the presence of a cleft or bifid uvula.

• Do not use this code for other forms of cleft palate; ensure the documentation specifically mentions the uvula.
• Consider additional codes for associated conditions or symptoms, such as speech impediments (e.g., R49.x) or recurrent otitis media, if documented.
• Review the medical record for any underlying syndromes or genetic conditions that may be linked to a cleft uvula, and code those separately if applicable.