Cleft Lip and Cleft Palate Repair - Diagnosis and Medical Coding

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.

trw ee.to,utsourcestrategies.com wSw

918-221-7769

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 –

www.outsourcestrategies.com

918-221-7769

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 –

www.outsourcestrategies.com

918-221-7769

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)

www.outsourcestrategies.com

918-221-7769



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

www.outsourcestrategies.com

918-221-7769

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.

www.outsourcestrategies.com

918-221-7769

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.

www.outsourcestrategies.com

918-221-7769