2024 ICD-10-CM Diagnosis Code Q36.9

Cleft lip, unilateral

ICD-10-CM Code:
Q36.9
ICD-10 Code for:
Cleft lip, unilateral
Is Billable?
Yes - Valid for Submission
Chronic Condition Indicator: [1]
Chronic
Code Navigator:

Code Classification

  • Congenital malformations, deformations and chromosomal abnormalities
    (Q00-Q99)
    • Cleft lip and cleft palate
      (Q35-Q37)
      • Cleft lip
        (Q36)

Q36.9 is a billable diagnosis code used to specify a medical diagnosis of cleft lip, unilateral. The code is valid during the current fiscal year for the submission of HIPAA-covered transactions from October 01, 2023 through September 30, 2024. The code is exempt from present on admission (POA) reporting for inpatient admissions to general acute care hospitals.

Approximate Synonyms

The following clinical terms are approximate synonyms or lay terms that might be used to identify the correct diagnosis code:

  • Auricular abnormality, cleft lip, ocular abnormality syndrome
  • Cleft lip
  • Cleft lip and cleft of alveolar process of maxilla
  • Cleft lip retinopathy syndrome
  • Cleft lip sequence
  • Complete cleft lip
  • Complete cleft lip
  • Complete cleft lip
  • Complete left cleft lip
  • Complete left cleft lip
  • Complete left cleft lip and complete cleft of left alveolar process of maxilla
  • Complete right cleft lip
  • Complete right cleft lip
  • Complete right cleft lip and complete cleft of right alveolar process of maxilla
  • Incomplete cleft lip
  • Incomplete cleft lip
  • Incomplete cleft lip
  • Incomplete left cleft lip
  • Incomplete left cleft lip
  • Incomplete left cleft lip and incomplete cleft of left alveolar process of maxilla
  • Incomplete right cleft lip
  • Incomplete right cleft lip
  • Incomplete right cleft lip and incomplete cleft of right alveolar process of maxilla
  • Left cleft lip
  • Microbrachycephaly, ptosis, cleft lip syndrome
  • Right cleft lip
  • Verloove Vanhorick Brubakk syndrome

Clinical Classification

Clinical Information

  • Cleft Lip

    congenital defect in the upper lip where the maxillary prominence fails to merge with the merged medial nasal prominences. it is thought to be caused by faulty migration of the mesoderm in the head region.

Tabular List of Diseases and Injuries

The following annotation back-references are applicable to this diagnosis code. The Tabular List of Diseases and Injuries is a list of ICD-10-CM codes, organized "head to toe" into chapters and sections with coding notes and guidance for inclusions, exclusions, descriptions and more.


Inclusion Terms

Inclusion Terms
These terms are the conditions for which that code is to be used. The terms may be synonyms of the code title, or, in the case of "other specified" codes, the terms are a list of the various conditions assigned to that code. The inclusion terms are not necessarily exhaustive. Additional terms found only in the Alphabetic Index may also be assigned to a code.
  • Cleft lip NOS

Index to Diseases and Injuries References

The following annotation back-references for this diagnosis code are found in the injuries and diseases index. The Index to Diseases and Injuries is an alphabetical listing of medical terms, with each term mapped to one or more ICD-10-CM code(s).

Present on Admission (POA)

Q36.9 is exempt from POA reporting - The Present on Admission (POA) indicator is used for diagnosis codes included in claims involving inpatient admissions to general acute care hospitals. POA indicators must be reported to CMS on each claim to facilitate the grouping of diagnoses codes into the proper Diagnostic Related Groups (DRG). CMS publishes a listing of specific diagnosis codes that are exempt from the POA reporting requirement. Review other POA exempt codes here.

CMS POA Indicator Options and Definitions

POA IndicatorReason for CodeCMS will pay the CC/MCC DRG?
YDiagnosis was present at time of inpatient admission.YES
NDiagnosis was not present at time of inpatient admission.NO
UDocumentation insufficient to determine if the condition was present at the time of inpatient admission.NO
WClinically undetermined - unable to clinically determine whether the condition was present at the time of inpatient admission.YES
1Unreported/Not used - Exempt from POA reporting. NO

Convert Q36.9 to ICD-9-CM

  • ICD-9-CM Code: 749.10 - Cleft lip NOS
    Approximate Flag - The approximate mapping means there is not an exact match between the ICD-10 and ICD-9 codes and the mapped code is not a precise representation of the original code.
  • ICD-9-CM Code: 749.11 - Unilat cleft lip-compl
    Approximate Flag - The approximate mapping means there is not an exact match between the ICD-10 and ICD-9 codes and the mapped code is not a precise representation of the original code.
  • ICD-9-CM Code: 749.12 - Unilat cleft lip-imcompl
    Approximate Flag - The approximate mapping means there is not an exact match between the ICD-10 and ICD-9 codes and the mapped code is not a precise representation of the original code.

Patient Education


Cleft Lip and Palate

Cleft lip and cleft palate are birth defects that occur when a baby's lip or mouth do not form properly. They happen early during pregnancy. A baby can have a cleft lip, a cleft palate, or both.

A cleft lip happens if the tissue that makes up the lip does not join completely before birth. This causes an opening in the upper lip. The opening can be a small slit or a large opening that goes through the lip into the nose. It can be on one or both sides of the lip or, rarely, in the middle of the lip.

Children with a cleft lip also can have a cleft palate. The roof of the mouth is called the "palate." With a cleft palate, the tissue that makes up the roof of the mouth does not join correctly. Babies may have both the front and back parts of the palate open, or they may have only one part open.

Children with a cleft lip or a cleft palate often have problems with feeding and talking. They also might have ear infections, hearing loss, and problems with their teeth.

Often, surgery can close the lip and palate. Cleft lip surgery is usually done before age 12 months, and cleft palate surgery is done before 18 months. Many children have other complications. They may need additional surgeries, dental and orthodontic care, and speech therapy as they get older. With treatment, most children with clefts do well and lead a healthy life.

Centers for Disease Control and Prevention


[Learn More in MedlinePlus]

Cleft Lip and Palate

Cleft lip with or without cleft palate is among the most common of birth defects.
[Learn More in MedlinePlus]

Code History

  • FY 2024 - No Change, effective from 10/1/2023 through 9/30/2024
  • FY 2023 - No Change, effective from 10/1/2022 through 9/30/2023
  • FY 2022 - No Change, effective from 10/1/2021 through 9/30/2022
  • FY 2021 - No Change, effective from 10/1/2020 through 9/30/2021
  • FY 2020 - No Change, effective from 10/1/2019 through 9/30/2020
  • FY 2019 - No Change, effective from 10/1/2018 through 9/30/2019
  • FY 2018 - No Change, effective from 10/1/2017 through 9/30/2018
  • FY 2017 - No Change, effective from 10/1/2016 through 9/30/2017
  • FY 2016 - New Code, effective from 10/1/2015 through 9/30/2016. This was the first year ICD-10-CM was implemented into the HIPAA code set.

Footnotes

[1] Chronic - a chronic condition code indicates a condition lasting 12 months or longer and its effect on the patient based on one or both of the following criteria:

  • The condition results in the need for ongoing intervention with medical products,treatment, services, and special equipment
  • The condition places limitations on self-care, independent living, and social interactions.