Q36: Cleft lip

Q36 refers to Cleft lip, which are among the most common craniofacial birth defects involving incomplete closure of the palate, lip, or both during early fetal development.

Symptoms

• Visible gap in the roof of the mouth (palate) – Seen in cleft palate (Q35)
• Separation of the upper lip – Characteristic of cleft lip (Q36)
• Feeding difficulties – Common due to inability to create suction
• Speech difficulties – Resulting from palate involvement
• Frequent ear infections – Due to Eustachian tube dysfunction

Diagnosis

Diagnosis of Cleft lip can occur prenatally through detailed ultrasound or postnatally during newborn physical examination. In some cases, MRI or CT imaging may be used to assess the extent of the defect.

ICD10 Code Usage

ICD10 code Q36 is essential for documenting cleft-related conditions in EHRs, supporting surgical planning for repair, speech therapy referral, insurance claims, and multidisciplinary cleft team management.

Related Codes

• Q35 – Cleft palate
• Q37 – Cleft palate with cleft lip

FAQs

Q1: What is ICD10 code Q36?
A: It refers to Cleft lip, which involves incomplete formation of the lip, palate, or both structures.

Q2: How are cleft lip and palate treated?
A: Surgical repair typically occurs within the first year of life, often followed by additional procedures during childhood.

Q3: Is speech therapy needed?
A: Yes, many children with cleft palate require speech therapy to address articulation and resonance issues.

Q4: What causes cleft lip or palate?
A: Causes can be genetic, environmental, or a combination, though exact triggers are often unknown.

Q5: Can cleft defects be detected before birth?
A: Yes, many cases can be identified during the second-trimester anomaly scan (ultrasound).

Conclusion

ICD10 code Q36 is critical for documenting Cleft lip, ensuring proper surgical repair, feeding support, and speech rehabilitation pathways to optimize outcomes for affected children.