Cleft lip, median

This code describes a congenital malformation characterized by a vertical division of the upper lip in the midline. This anomaly results from incomplete fusion of the medial nasal prominences during embryonic development. It is a rare form of cleft lip, distinct from the more common unilateral or bilateral clefts.

Apply this code when documentation specifically identifies a "median cleft lip" or "midline cleft lip" as the patient's diagnosis. This diagnosis is typically made at birth or during early infancy based on physical examination. Supporting documentation will include physician notes detailing the location and nature of the cleft.

• Do not confuse this with other types of cleft lip (e.g., unilateral, bilateral), which have distinct codes.
• Always review documentation for associated cleft palate, as separate codes are required for combined defects.
• Ensure the documentation clearly specifies "median" to differentiate from other cleft lip presentations.