Cleft soft palate with bilateral cleft lip

This code identifies a congenital malformation characterized by a complete separation of the soft palate, accompanied by a cleft extending through the lip on both sides of the philtrum. This condition results from incomplete fusion of facial structures during embryonic development.

Assign this code for patients diagnosed with a cleft involving the soft palate and a bilateral cleft lip. Documentation should clearly specify the involvement of the soft palate and the bilateral nature of the lip cleft, often noted in neonate assessments or pediatric ENT/craniofacial specialist reports.

• Ensure documentation explicitly states "soft palate" involvement; do not use for clefts of the hard palate only.
• Verify the bilateral nature of the lip cleft; unilateral clefts require different codes.
• Consider sequencing with codes for associated anomalies or complications, such as feeding difficulties or speech impairments.