Cleft lip ICD 10 codes
Cleft Lip ICD 10 code is used in the diagnosis and treatment of a congenital, craniofacial condition that occurs when the fusion of the upper lip during fetal development is incomplete. This results in a separation in the lip that may affect one or both sides of the lip, and can range from a small notch or extend all of the way up into the nostril.
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Speech-language pathologists play a critical role in the management of cleft lip. Of the children with cleft lip and/or palate who have reconstructive surgery, 50% are referred for speech therapy due to deviations in their speech.
In speech therapy, accurate diagnosis and coding are critical. The International Classification of Diseases, 10th edition (ICD-10) is the official coding system created by the CDC. Speech therapists use ICD-10 codes that match specific diagnoses when completing documentation such as evaluations and treatment notes. This helps ensure consistency among different health professionals.
By documenting the appropriate Cleft Lip ICD 10 codes, SLPs can help ensure accurate communication among other professionals. Accurate coding can also help therapists avoid denials for reimbursement from insurance, and assist with determining which treatment interventions should be utilized.
Let’s take a deeper dive into the diagnosis of cleft lip. We’ll explore ICD-10 codes, evidence-based assessment and intervention protocols, and how cleft lip can affect a child’s speech and language development.
Speech-language pathologists play a critical role in the management of cleft lip. Of the children with cleft lip and/or palate who have reconstructive surgery, 50% are referred for speech therapy due to deviations in their speech.
In speech therapy, accurate diagnosis and coding are critical. The International Classification of Diseases, 10th edition (ICD-10) is the official coding system created by the CDC. Speech therapists use ICD-10 codes that match specific diagnoses when completing documentation such as evaluations and treatment notes. This helps ensure consistency among different health professionals.
By documenting the appropriate Cleft Lip ICD 10 codes, SLPs can help ensure accurate communication among other professionals. Accurate coding can also help therapists avoid denials for reimbursement from insurance, and assist with determining which treatment interventions should be utilized.
Let’s take a deeper dive into the diagnosis of cleft lip. We’ll explore ICD-10 codes, evidence-based assessment and intervention protocols, and how cleft lip can affect a child’s speech and language development.
What is Cleft Lip?
The Mayo Clinic defines cleft lip as an opening or split in the upper lip. Cleft lip can occur in isolation or in addition to a cleft palate. Both cleft lip and cleft palate occur when these developing facial structures only partially close in utero.
According to research, cleft lip is one of the most common birth defects (congenital anomalies) in the world. The CDC states that approximately 1 in every 1,600 babies in the U.S. is born with cleft lip and cleft palate, and about 1 in every 2,800 is born with cleft lip without cleft palate.
Types of cleft lip
Cleft lip is not limited to one condition. The various conditions are list in the table below.
Condition | Description |
|---|---|
Unilateral cleft lip | A cleft affecting one side of the lip, with or without a cleft palate. |
Bilateral cleft lip | A cleft affecting both sides of the lip. |
Complete cleft lip | A cleft lip that extends all of the way up to the nostril. |
Incomplete cleft lip | A cleft in the lip that does not extend up to the nostril. |
Isolated cleft lip | A cleft lip is present without a cleft cleft palate. |
Microform (“formes fruste”) | A small indentation on one or both sides of the lip. The mildest version of a cleft lip, which may appear as a repaired cleft lip or vertical scar. |
In many cases, the cause of a cleft lip is often unknown. The condition can occur in children who do not have any other medical diagnoses.
According to the American Speech-Language-Hearing Association (ASHA), certain risk factors can increase the likelihood of cleft lip and palate. These include:
- Family history of cleft lip and palate
- Environmental factors (i.e., exposure to certain environmental substances like drugs, tobacco, and alcohol)
- Ethnicity (within Asian, Latino, and Native American ethnicities, cleft lip and palate is more common)
- Gender: There is a higher incidence of cleft lip in males.
Cleft lip can have significant effects on a child’s speech, communication, and feeding.
Abnormal Resonance: Individuals with cleft lip and cleft palate may have abnormal nasal airflow. This can include too much sound energy (hypernasality), too little nasal sound energy (hyponasality), or a mix of both.
Articulation Issues: Speech sound errors may occur in individuals with cleft lip and palate. A child with only a cleft lip may not demonstrate difficulties with articulation.
Feeding and Swallowing Difficulties
- Babies born with a cleft lip may have feeding difficulties.
- The baby may have difficulty creating an adequate seal, and may benefit from using a specialized bottle.
- These are typically not as significant as feeding issues that can be experienced by a baby with cleft palate.
What is the ICD code for Cleft lip?
The CDC’s ICD-10 coding system serves as a standardized system for coding and documentation of a cleft lip diagnosis. Unique Cleft Lip ICD 10 codes are assigned for specific types of this condition:
- Q36.0: Bilateral complete cleft lip
- Q36.9: Unilateral cleft lip
- Q37.8: Unspecified cleft palate with bilateral cleft lip
- Q37.9: Unspecified cleft palate with a unilateral cleft lip
It’s important for speech therapists to adhere to the coding guidelines that are outlined by the ICD-10 for Cleft Lip ICD 10 codes. Following these guidelines can help ensure accurate documentation and reporting of the correct diagnosis of cleft lip. SLPs should also distinguish a diagnosis of isolated cleft lip from related conditions, for example, Q35.9 cleft palate.
Clinical assessment and diagnosis of Cleft Lip
Assessment of cleft lip and associated speech disorders typically involves a comprehensive evaluation from a multidisciplinary team that may include:
- Speech therapist
- Plastic surgeon
- ENT (ear nose and throat doctor)
- Nurse
- Pediatrician
- Social worker
- Dentist
- Orthodontist
Through this collaborative approach, an accurate diagnosis of the presence and type of cleft lip, as well as an appropriate intervention plan can be made.
Speech therapists play an essential role in the assessment and diagnosis of cleft lip. An assessment of cleft lip consists of a comprehensive evaluation of the child’s speech production skills, articulation, resonance, and language skills.
A speech therapy assessment for a client with cleft lip typically includes a thorough oral motor examination, a review of medical history and case history provided by the caregivers, clinical observations, standardized tests, and instrumental assessments.
If the child has both a cleft lip and cleft palate, the speech therapist may present sentences containing oral pressure consonants (such as the /p/ sound) for the child to imitate. This can aid in assessing nasality.
An articulation assessment such as the Goldman Fristoe Test of Articulation - 3rd Edition (GFTA-3) can also be used to assess the child’s articulation skills.
SLP should include the most accurate Cleft Lip ICD 10 code for the specific type of this condition and any other associated speech disorders when providing documentation such as treatment notes and assessments.
This can help ensure that there is clear communication among families as well as within the multidisciplinary team, and that an appropriate treatment plan is developed.
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Treatment and intervention strategies
Ongoing collaboration from the multidisciplinary team is recommended to provide comprehensive, effective intervention for a client with cleft lip. Communication between the team can help professionals make informed decisions on recommendations for care, such as therapy and surgical repairs.
The areas targeted in speech therapy for a child with cleft lip may involve articulation therapy, resonance training, and support for language development. Addressing possible social-emotional difficulties with clients and families should also be considered.
SLPs are able to track a client’s progress over time while using Cleft Lip ICD 10 coding. Therapists can periodically complete re-evaluations that include Cleft Lip ICD 10 coding and accompanying severity levels. These can be compared and analyzed to assist the therapist when making informed decisions about a child’s intervention plan.
Impact on speech and language development
Cleft lip can affect a child’s production or articulation. Speech sounds known as bilabials, which require lip and oral closure (such as /p/, /b/, and /m/) may be challenging for children with cleft lip to produce.
If the cleft lip occurs in a child who also has a cleft palate, treatment may also address resonance due to possible hypernasality. This is caused by inadequate closure of the velopharyngeal port, separating the nasal and oral cavities.
Overall, cleft lip can result in reduced speech intelligibility, making it difficult for the client to effectively communicate with others.
Children with cleft lip should also be assessed for possible delays in language development. This can result from a child’s inability to practice and refine language skills secondary to articulation difficulties.
Early intervention is key in addressing delays in speech and language development from a young age to ensure the child meets their full potential.
Speech therapy for clients with cleft lip may involve articulation exercises that target specific speech sounds. If the child shows delays in language development, intervention may also include the use of strategies for improving the child’s vocabulary.
Ethical and cultural considerations
Therapists should make careful considerations to keep ethical and cultural guidelines in mind when working with individuals with cleft lip and their families.
Maintaining cultural sensitivity as well as awareness of the possible social and emotional impact of cleft lip on individuals and families is important. Creating a supportive, inclusive therapeutic environment for the client and their family is recommended.
Professional development and resources
Several training opportunities are available for speech therapists to continue learning about cleft lip management. This includes resources from the ACPA (American Cleft lip Craniofacial Association) and ASHA.
Speech therapists can also consider engaging in support networks for guidance in working with individuals with cleft lip. ASHA special interest groups, professional social media groups, online forums, and local professional organizations offer therapists the opportunity to share experiences and seek guidance from each other.
Cleft lip may occur in isolation or in addition to cleft palate, and is a common birth defect. The diagnosis can affect a child’s speech, intelligibility, resonance, and language skills. Speech therapists should know the correct ICD-10 codes to use when referring to specific types of cleft lip to ensure accurate documentation.
Speech therapists have an essential role in the comprehensive cleft lip management. The SLP provides accurate diagnoses, evidence-based treatment techniques, and collaboration with a multidisciplinary team, to improve the child’s communication skills.
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References
Niinomi, K., Ueki, S., Fujita, Y., Kitao, M., Matsunaka, E., Kumagai, Y., & Ike, M. (2022). Differences in specific concerns perceived by parents of children with cleft lip and/or palate based on the types of cleft. International Journal of Paediatric Dentistry, 32(3), 304-313. DOI: Differences in specific concerns perceived by parents of children with cleft lip and/or palate based on the types of cleft
Salari, N., Darvishi, N., Heydari, M., Bokaee, S., Darvishi, F., & Mohammadi, M. (2022). Global prevalence of cleft palate, cleft lip and cleft palate and lip: A comprehensive systematic review and meta-analysis. Journal of stomatology, oral and maxillofacial surgery, 123(2), 110-120. DOI: https://doi.org/10.1016/j.jormas.2021.05.008
Sand, A., Hagberg, E., & Lohmander, A. (2022). On the benefits of speech-language therapy for individuals born with cleft palate: A systematic review and meta-analysis of individual participant data. Journal of Speech, Language, and Hearing Research, 65(2), 555-573. DOI: https://doi.org/10.1044/2021_JSLHR-21-00367
