Unspecified cleft palate with unilateral cleft lip

This code signifies a congenital malformation characterized by a split in the roof of the mouth (palate) of an unspecified type, occurring concurrently with a cleft lip that affects only one side of the face. The specific type of cleft palate (e.g., hard, soft, complete) is not documented.

Use this code when documentation clearly indicates the presence of both a cleft palate and a unilateral cleft lip, but the specific type or extent of the palatal cleft is not specified. This is often an interim code used when initial assessment confirms the combined defect but further diagnostic details are pending or unavailable.

• Avoid using this code if the type of cleft palate (e.g., hard, soft, complete) is documented; instead, use a more specific Q37 subcategory.
• Ensure documentation explicitly states "unilateral" for the cleft lip; otherwise, consider codes for bilateral or unspecified cleft lip.
• This code represents a combined defect; do not code cleft palate and cleft lip separately if they are part of the same congenital anomaly.