Cleft hard and soft palate with unilateral cleft lip

This code represents a congenital malformation where there is an incomplete closure of both the hard and soft palate, accompanied by a cleft on one side of the upper lip. This condition results in an opening between the oral and nasal cavities and a visible separation of the upper lip tissue.

Use this code for patients diagnosed with a complete cleft involving the hard palate, soft palate, and a unilateral cleft lip. Documentation should clearly specify the involvement of both hard and soft palates, as well as the unilateral nature of the lip cleft.

• Ensure documentation specifies involvement of both hard and soft palates; codes exist for isolated clefts.
• Verify the laterality of the lip cleft (unilateral vs. bilateral) as this impacts code selection.
• Do not use this code if the cleft lip is bilateral; a different code would be appropriate.