Cleft Palate ICD 10 code

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Cleft palate ICD 10 code is used to diagnose and bill for a congenital condition that refers to an opening in the hard or soft palate, the bony front part or back area made of muscle, on the roof of the mouth. Having a cleft palate can affect several areas of an individual’s speech, communication and feeding abilities.

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Accurate diagnosis and coding of cleft palate are essential in order for speech-language pathologists to ensure effective treatment, accurate communication among professionals, and for reimbursement purposes.

ICD-10 stands for International Classification of Diseases, 10th edition, and it is the official coding system created by the CDC. Therapists use ICD-10 codes to match specific diagnoses. This helps ensure consistency among different health professionals.

Using the incorrect ICD-10 code on documentation can result in denials from insurance. When working with a client who has a diagnosis of cleft palate, it’s essential that SLPs use the correct cleft palate ICD 10 code on documentation such as treatment notes and evaluations.

Follow along here as we further define cleft palate and explore cleft palate ICD 10 codes for the diagnosis. We’ll discuss evidence-based assessment and intervention procedures, the impact of cleft palate on speech and language development, and provide suggestions for helpful resources.



What is Cleft Palate?

According to the Mayo Clinic, a cleft palate is an opening or split in the roof of the mouth (palate) that results when the developing facial structures do not close completely in utero.

Cleft palate is one of the most common birth defects (congenital anomalies) around the world. The CDC reports that approximately 1 in every 1,700 babies in the U.S. is born with cleft palate.

Some babies are born with a cleft palate and cleft lip, and some are born with a cleft palate alone.

Types of cleft palate include:
  • Complete cleft palate: A cleft in both the hard and soft palate. This exposes the oral and nasal cavities.

  • Incomplete cleft palate: A cleft in the soft palate, but not in the hard palate.

  • Submucous cleft palate: A cleft in the hard and/or soft palate that is covered by the mucous membrane which lines the roof of the mouth.

  • Alveolar cleft: A gap in the upper gum line that can cause a hole from the mouth to the nose. Alveolar clefts can be one-sided (one gap) or two-sided (two gaps).

  • Isolated cleft palate: A cleft palate is present without a cleft lip.

The cause of a cleft palate is often unknown and can occur in children who do not have any other medical conditions.

Certain factors may play a role in a child having a cleft palate, including:
  • Certain medical conditions

  • Genetic factors (family history)

  • Environmental factors, such as maternal behaviors (smoking during pregnancy, diabetes, the use of certain medications)

  • Ethnicity (Cleft lip and palates are known to be more common in Asian, Latino, and Native American ethnicities)

Having a cleft palate can affect several areas of a child’s speech and communication, such as:

Resonance

  • Abnormal nasal airflow (hypernasality or too much sound energy), hyponasality (too little nasal sound energy), or a mix of both
  • Velopharyngeal dysfunction can be present if the child’s speech is hypernasal.

Articulation

  • Cleft palate speech: Sound errors that are commonly seen in children with cleft palate
    • Glottal stops
    • Pharyngeal fricatives
    • Nasal fricatives
    • Mid-dorsum palatal stops

Nasal or facial grimaces

Altered laryngeal voice quality

  • Children may be at a higher risk for vocal dysfunction due to factors like VPI and distorted anatomy.

Expressive language delays

  • Reduced expressive vocabulary, possibly due to the child’s reduced production of words containing high-pressure consonant sounds.

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Cleft palate ICD 10 codes

The ICD-10 provides a standardized system for coding and documentation of cleft palate diagnosis. Below is a list of cleft palate ICD 10 codes.

ICD 10 code

Description

Q35.1

Cleft hard palate

Q35.3

Cleft soft palate

Q35.5

Cleft hard palate with cleft soft palate

Q37.8

Unspecified cleft palate with bilateral cleft lip

Q35.9

Posterior cleft palate


Speech therapists should follow the coding guidelines provided by the ICD-10. Adhering to these guidelines helps ensure accurate documentation and reporting of the specific cleft palate diagnosis. It’s also important for SLPs to distinguish a diagnosis of isolated cleft palate from related conditions, for example, Q36.9 Cleft lip, unilateral.

Clinical assessment and diagnosis

Speech therapists play a critical role in the assessment and diagnosis of cleft palate. An assessment of cleft palate consists of a comprehensive evaluation of the child’s speech production skills, articulation, resonance, and language skills.

The SLP’s assessment in a client with cleft palate typically includes a thorough oral motor examination, clinical observations, standardized tests, and instrumental assessments.

For example, the SLP may ask the child to say sentences that contain several oral pressure consonants, such as “pick up a puppy” to assess his or her nasality.

A collaborative approach to diagnosis of cleft palate is essential. The multidisciplinary team may include a speech therapist, ENT, plastic surgeon, audiologist, primary care physician, and other healthcare professionals.

It’s important that SLPs include the accurate ICD-10 code in documentation, including detailed information about the specific type and severity of the cleft palate and any associated speech disorders. This can ensure clear communication between other involved professionals, families, and the development of an appropriate treatment plan.



Treatment and intervention strategies

Effective intervention for a client with cleft palate involves an ongoing multidisciplinary team approach to ensure comprehensive care is provided. The team may include professionals such as therapists, surgeons, ENT, and orthodontists.

Speech therapy for individuals with cleft palate may involve articulation therapy, resonance training, support for language development, and family and client counseling regarding possible social and communication issues that may be present.

Using ICD-10 coding, the SLP is able to track the client’s progress over time. Periodic re-evaluations that include ICD-10 coding and accompanying severity levels can be compared to help the clinician make informed decisions about the client’s treatment plan.

Impact on speech and language development

Cleft palate can affect the child’s production or articulation of certain speech sounds. Sounds requiring oral closure and pressure such as /p/ and /b/ may be difficult for individuals. This can lead to disruptions in nasal resonance or airflow.

Some individuals with cleft palate experience delays in language development, such as reduced expressive language skills. This may stem from articulation difficulties or secondary factors such as recurrent ear infections.

Addressing communication difficulties in individuals with cleft palate may involve articulation exercises that target specific speech sounds and discrimination or improved control between nasal and oral airflow.

Ethical and cultural considerations

It is critical to keep certain ethical and cultural considerations in mind when working with individuals with cleft palate and their families.

SLPs should maintain cultural sensitivity and awareness of the social and emotional impact of cleft palate on individuals and families. Therapists can create a supportive, inclusive therapeutic environment for the client and their family.


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Professional development and resources

Speech therapists can access specialized training on cleft palate management through organizations such as the ACPA (American Cleft Palate Craniofacial Association) and ASHA.

Staying up to date on cleft palate ICD 10 codes is critical to ensure ongoing compliance with guidelines and updates.

SLPs may also engage in support networks to guide them in working with individuals with cleft palate. Professional social media groups, ASHA special interest groups, local professional organizations, and online forums can offer SLPs opportunities to share experiences and seek guidance from one another.

Summary

Cleft palate is one of the most commonly occuring congenital abnormalities. Speech therapists should know the specific cleft palate ICD 10 codes for various types of the condition, to ensure accurate documentation.

SLPs play a critical role in the comprehensive management of cleft palate. By providing accurate diagnoses, evidence-based treatment techniques, and ongoing collaboration with a multidisciplinary team, therapists can effectively improve the communication skills in those with cleft palate.

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Resources

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References

Lancaster, H. S., Lien, K. M., Chow, J. C., Frey, J. R., Scherer, N. J., & Kaiser, A. P. (2020). Early speech and language development in children with nonsyndromic cleft lip and/or palate: A meta-analysis. Journal of Speech, Language, and Hearing Research, 63(1), 14-31. DOI: Early Speech and Language Development in Children With Nonsyndromic Cleft Lip and/or Palate: A Meta-Analysis

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://www.sciencedirect.com/science/article/abs/pii/S246878552100118X?via%3Dihub

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: On the Benefits of Speech-Language Therapy for Individuals Born With Cleft Palate: A Systematic Review and Meta-Analysis of Individual Participant Data

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