Unspecified cleft palate with bilateral cleft lip

This code identifies a congenital malformation characterized by a split in the roof of the mouth (palate) of an unspecified type, occurring concurrently with a cleft in both sides of the upper lip. The specific nature or extent of the palatal cleft is not documented.

Apply this code when documentation clearly indicates the presence of both a bilateral cleft lip and a cleft palate, but the type or specific characteristics of the palatal cleft are not specified. This is appropriate when the provider has not further elaborated on the palatal defect beyond its existence.

• Only use this code when the type of cleft palate is truly unspecified; if the type is documented (e.g., hard, soft, complete), use a more specific code.
• Do not use this code if only a cleft lip is present, or if the cleft lip is unilateral.
• Review documentation carefully for any further details on the cleft palate that would allow for a more precise code selection.