Cleft soft palate with unilateral cleft lip

This code identifies a congenital malformation characterized by a division in the soft tissue at the back of the roof of the mouth, accompanied by a cleft on only one side of the upper lip. This condition results from incomplete fusion of facial structures during fetal development.

Apply this code for patients diagnosed with a cleft involving the soft palate and a unilateral cleft of the lip. Documentation should clearly specify the involvement of the soft palate and confirm the unilateral nature of the lip cleft. This code is appropriate for initial diagnosis and subsequent encounters related to this specific malformation.

• Ensure documentation explicitly states "soft palate" and "unilateral cleft lip" to support this specific code.
• Do not use this code if the hard palate is also involved; a more specific code for combined soft and hard palate clefts would be appropriate.
• Sequence this code as a primary diagnosis when it is the reason for the encounter, or as a secondary diagnosis when managing related complications or treatments.