Cleft lip, bilateral

This code represents a congenital malformation characterized by a split or opening in the upper lip on both sides of the philtrum. This condition results from incomplete fusion of the facial processes during embryonic development, affecting the aesthetic appearance and potentially interfering with feeding and speech.

Use this code for patients diagnosed with a cleft affecting both sides of the upper lip. Documentation should clearly specify the bilateral nature of the cleft lip, often noted in initial birth records, pediatric evaluations, or surgical consultations. This code is applicable for initial diagnosis and subsequent encounters related to the management of this specific condition.

• Differentiate from unilateral cleft lip; laterality must be explicitly documented.
• Always check for co-occurring cleft palate (Q35.-) and code separately if present.
• Review documentation for associated syndromes or anomalies, which may require additional coding.