Cleft hard and soft palate with bilateral cleft lip

This code identifies a congenital malformation characterized by a complete separation of both the hard and soft palates, accompanied by a cleft on both sides of the upper lip. This condition results from incomplete fusion of facial structures during embryonic development.

Use this code for patients diagnosed with a complete cleft involving both the hard and soft palates, in conjunction with a bilateral cleft lip. Documentation should explicitly state the involvement of both hard and soft palates and confirm the bilateral nature of the lip cleft.

• Ensure documentation specifies involvement of both hard and soft palates, not just one or the other.
• Verify the cleft lip is explicitly documented as bilateral; unilateral cleft lip with cleft palate uses a different code.
• Consider additional codes for associated anomalies or complications, such as feeding difficulties or speech impairments.