The article discusses cleft lip and cleft palate conditions and the various medical codes to accurately document this genetic disorder.

1. Cleft Lip and Cleft Palate Repair
– Diagnosis and Medical Coding
The article discusses cleft lip
and cleft palate conditions
and the various medical codes
to accurately document this
genetic disorder.
wSwtrwee.to,utsourcestrategies.com 918-221-7769

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Cleft lip and cleft palate are congenital deformities of the face that occur before a baby is
born. Known as one of the most common birth defects, cleft lip and cleft palate are
openings or splits/gaps in the upper lip, the roof of the mouth (palate) or both. These
splits/gaps occur when parts of the baby’s face don’t join together properly during
development in the womb. The exact cause of these facial and oral malformations is
unknown. However, a combination of genetic and environmental factors can contribute to
this birth disorder. If not corrected, this condition can cause severe complications such as
dental problems, speech problems, ear infections and possible hearing loss and feeding
problems. Billing and coding for this condition is quite challenging, as there are several
applicable rules. For accurate clinical documentation of this birth disorder, most
otolaryngologists rely on the services of reliable medical billing outsourcing companies.
Reports from the Centers for Disease Control and Prevention (CDC) suggest that around
2,650 infants are born with a cleft palate, and 4,440 babies are born with a cleft lip, either
with or without a cleft palate. It is estimated that males are twice as likely to have cleft lip,
cleft palate, or both compared to females. Females are more likely to have a cleft palate
only. The potential risk factors associated with this condition include – family history,
diabetes and obesity, and exposure to certain substances during pregnancy.
Symptoms
Generally, a cleft (split) in the lip or palate is identifiable at birth. The symptoms of these
abnormalities may appear during the initial examination by a pediatrician. The type and
degree of abnormality can vary and on inspection of the mouth and lips, the abnormality
can be clearly noted (as the condition involves incomplete closure of either the lip, roof of
the mouth, or both).
A cleft lip and cleft palate may normally appear as -
 A split in the lip and roof of the mouth (palate)
 A split in the roof of the mouth (that doesn't affect the appearance of the face)
 A split in the lip that appears as a small notch in the lip or extends from the lip
through the upper gum and palate into the bottom of the nose
However, less commonly a cleft may develop in the muscles of the soft palate (sub mucous
cleft palate) which often gets unnoticed at birth and may not be diagnosed until later when
symptoms develop. Common signs and symptoms of sub mucous cleft palate include –

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chronic ear infections, nasal speaking voice, difficulty with feeding and difficulty swallowing
(with potential for liquids or foods to come out the nose).
How to Diagnose and Document Cleft Lip and Palate
Most cases of cleft lip and cleft palate can be clearly identified at the time of birth and hence
don’t require any special diagnosis tests. However, nowadays an ultrasound scan can
correctly detect facial clefts from around the 13th week of pregnancy. A prenatal ultrasound
uses sound waves to create images of the developing fetus. Physicians can detect a
difference in the facial structures when analyzing the images of the developing fetus.
If prenatal ultrasound shows a cleft, your physician may suggest a fluid test, to take a
sample of amniotic fluid from your uterus (amniocentesis). The test may indicate whether
the fetus has inherited a genetic syndrome that may potentially cause any other birth
defects. On the other hand, cleft palate that occurs alone is more difficult to view using an
ultrasound.
Treatment for cleft lip and cleft palate aims to improve the child's ability to eat, speak and
hear normally and to achieve a normal facial appearance. A team of physicians comprising
ENTs (also called otorhinolaryngologists), pediatricians, pediatric dentists, orthodontists,
speech therapists and surgeons who specialize in cleft repair, such as plastic surgeons or
ENTs may conduct various tests for children with this condition.
Treatment involves surgical techniques to repair cleft lip and palate, reconstruct the affected
areas, and prevent or treat related complications. Surgical procedures may include - cleft lip
repair, cleft palate repair, ear tube surgery and additional procedures to reconstruct or
improve the appearance of the mouth, lip and nose. Further treatment for complications
caused by cleft lip and cleft palate include - speech therapy, orthodontic adjustments to the
teeth and bite (like braces), feeding strategies (like using a special bottle nipple or feeder)
and using hearing aids or other assistive devices.
Medical Codes to Use to Report the Condition
Otolaryngology medical coding involves the use of specific ICD-10 codes and CPT codes
to document any such conditions, including cleft lip and cleft palate. The following medical
codes are used –

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ICD-10 Codes
Q35 Cleft palate
 Q35.1 - Cleft hard palate
 Q35.3 - Cleft soft palate
 Q35.5 - Cleft hard palate with cleft soft palate
 Q35.7 - Cleft uvula
 Q35.9 - Cleft palate, unspecified
Q36 - Cleft lip
 Q36.0 - Cleft lip, bilateral
 Q36.1 - Cleft lip, median
 Q36.9 - Cleft lip, unilateral
Q37 - Cleft palate with cleft lip
 Q37.0 - Cleft hard palate with bilateral cleft lip
 Q37.1 - Cleft hard palate with unilateral cleft lip
 Q37.2 - Cleft soft palate with bilateral cleft lip
 Q37.3 - Cleft soft palate with unilateral cleft lip
 Q37.4 - Cleft hard and soft palate with bilateral cleft lip
 Q37.5 - Cleft hard and soft palate with unilateral cleft lip
 Q37.8 - Unspecified cleft palate with bilateral cleft lip
 Q37.9 - Unspecified cleft palate with unilateral cleft lip
CPT Codes
Rhinoplasty – Nasal deformities can develop during the early teen years, when the face
becomes more developed. Rhinoplasty is a surgical procedure done to correct breathing
problems (related to the nose) or correct disfigurement resulting from trauma or birth
defects.
 30400 - Rhinoplasty, primary; lateral and alar cartilages and/or elevation of nasal tip
 30410 - Rhinoplasty, primary; complete, external parts including bony pyramid,
lateral and alar cartilages, and/or elevation of nasal tip
 30420 - Rhinoplasty, primary; including major septal repair
 30430 - Rhinoplasty, secondary; minor revision (small amount of nasal tip work)

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 30435 - Rhinoplasty, secondary; intermediate revision (bony work with osteotomies)
 30450 - Rhinoplasty, secondary; major revision (nasal tip work and osteotomies)
 30460 - Rhinoplasty for nasal deformity secondary to congenital cleft lip and/or
palate, including columellar lengthening; tip only
 30462 - Rhinoplasty for nasal deformity secondary to congenital cleft lip and/or
palate, including columellar lengthening; tip, septum, osteotomies
 30465 - Repair of nasal vestibular stenosis (e.g., spreader grafting, lateral nasal wall
reconstruction)
 30560 - Lysis intranasal synechia
 30620 - Septal or other intranasal dermatoplasty (does not include obtaining graft)
 30120 - Excision or surgical planing of skin of nose for rhinophyma
Cleft Lip Repair – Cleft lip develops when the tissues forming the upper lip area do not
fuse. This can either occur in an incomplete fashion, where the lip is separated but the nasal
sill remains intact or in a complete fashion where the cleft extends through the nasal sill.
This procedure is usually performed when the child is 3 months old. The procedure codes
include -
 40700 - Plastic repair of cleft lip/nasal deformity; primary, partial or complete,
unilateral
 40701 - Plastic repair of cleft lip/nasal deformity; primary bilateral, 1-stage
procedure
 40702 - Plastic repair of cleft lip/nasal deformity; primary bilateral, 1 of 2 stages
 40720 - Plastic repair of cleft lip/nasal deformity; secondary, by recreation of defect
and re-closure
 40761 - Plastic repair of cleft lip/nasal deformity with cross lip pedicle flap
(AbbeEstlander type), including sectioning and inserting of pedicle
When a bilateral cleft lip is repaired in a two-stage procedure, report CPT code 40702 for
each of the two stages. The code descriptor indicates “1 of 2 stages,” but does not
differentiate between the first and second stages. On the other hand, if a patient develops
deformity, requiring a revision of the previous repair, report CPT code 40720. Revisions are
generally necessary due to poor healing, dehiscence, or scar contracture from the initial
surgery.
Cleft Palate Repair – Cleft palate repair is done when a child is approximately one year
old. In a complete cleft palate, the defect extends through the soft and hard palate. On the

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other hand, an incomplete cleft palate involves a separation that partially spreads through
the roof of the mouth.
 42200 - Palatoplasty for cleft palate, soft and/or hard palate only
 42205 - Palatoplasty for cleft palate, with closure of alveolar ridge; soft tissue only
 42210 - Palatoplasty for cleft palate, with bone graft to alveolar ridge (includes
obtaining graft)
 42215 - Palatoplasty for cleft palate; major revision
 42220 - Palatoplasty for cleft palate; secondary lengthening procedure
 42225 - Palatoplasty for cleft palate; attachment pharyngeal flap
 42226 - Lengthening of palate, and pharyngeal flap
 42227 - Lengthening of palate, with island flap
 42235 - Repair of anterior palate, including vomer flap
 42260 - Repair of nasolabial fistula
 42280 - Maxillary impression for palatal prosthesis
 42281 - Insertion of pin-retained palatal prosthesis
HCPCS Codes
 D5931 - Obturator prosthesis, surgical
 D5932 - Obturator prosthesis, definitive
 D5933 - Obturator prosthesis, modification
 D5936 - Obturator prosthesis, interim
 D5954 - Palatal augmentation prosthesis
 D5955 - Palatal lift prosthesis, definitive
 D5958 - Palatal lift prosthesis, interim
 D5959 - Palatal lift prosthesis, modification
A cleft lip and cleft palate condition can lead to several medical, behavioral, and social
difficulties, but nowadays, this condition can be effectively corrected by surgery. While
cases of cleft lip and cleft palate can't be prevented, taking several important steps can
possibly lower your potential risks. It is important to check with physicians before taking
any medications during pregnancy. Reduce the consumption of alcohol or tobacco during
pregnancy as it increases the risk of having a baby with a birth defect. In addition, if you
have a family history of cleft lip and cleft palate, you can seek genetic counseling before
pregnancy.

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Medical coding for cleft lip and cleft palate deformities can be a challenging process. For
accurate and timely medical billing and claims submission, healthcare practices can
outsource their medical coding tasks to an established medical billing company that
provides the services of AAPC-certified coding specialists.