Cleft lip, unilateral

This code describes a congenital malformation characterized by a split or opening in the upper lip on one side, resulting from incomplete fusion during fetal development. It can range in severity from a small notch to a complete separation extending into the nostril. This condition often affects feeding, speech, and facial aesthetics.

Use this code for documented cases of a cleft lip that is specifically identified as unilateral, without further specification of its completeness or the presence of a cleft palate. Documentation should clearly state "unilateral cleft lip" or similar terminology. This code is appropriate when the laterality is known but the extent (e.g., incomplete, complete) is not specified.

• Do not use this code if the documentation specifies a bilateral cleft lip; use the appropriate bilateral code.
• If the documentation specifies the completeness of the unilateral cleft lip (e.g., incomplete, complete), use the more specific code.
• Always review documentation for any associated cleft palate, as this would require additional coding.