Cleft hard palate with bilateral cleft lip

This code signifies a congenital malformation characterized by a complete or partial opening in the hard palate, combined with a cleft (split) on both sides of the upper lip. This condition results from incomplete fusion of facial structures during embryonic development.

Apply this code when documentation explicitly states a diagnosis of cleft hard palate alongside a bilateral cleft lip. This is typically identified at birth or during early infancy through physical examination. Supporting documentation will include physician notes detailing the specific anatomical involvement.

• Differentiate from unilateral cleft lip (Q36.-) or isolated cleft palate (Q35.-).
• Always review documentation for laterality of the cleft lip (unilateral vs. bilateral) and the specific part of the palate involved (hard, soft, or both).
• Consider additional codes for associated anomalies or complications, such as feeding difficulties or speech impairments.