ICD-10-CM Code Q36.9

Cleft lip, unilateral

Version 2020 Billable Code POA Exempt

Valid for Submission

Q36.9 is a billable code used to specify a medical diagnosis of cleft lip, unilateral. The code is valid for the year 2020 for the submission of HIPAA-covered transactions. The ICD-10-CM code Q36.9 might also be used to specify conditions or terms like auricular abnormality, cleft lip, ocular abnormality syndrome, cleft lip, cleft lip and alveolus, cleft lip retinopathy syndrome, cleft lip sequence, complete left cleft lip, etc The code is exempt from present on admission (POA) reporting for inpatient admissions to general acute care hospitals.

ICD-10:Q36.9
Short Description:Cleft lip, unilateral
Long Description:Cleft lip, unilateral

Tabular List of Diseases and Injuries

The Tabular List of Diseases and Injuries is a list of ICD-10 codes, organized "head to toe" into chapters and sections with guidance for inclusions, exclusions, descriptions and more. The following references are applicable to the code Q36.9:

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

The Index to Diseases and Injuries is an alphabetical listing of medical terms, with each term mapped to one or more ICD-10 code(s). The following references for the code Q36.9 are found in the index:


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 alveolus
  • Cleft lip retinopathy syndrome
  • Cleft lip sequence
  • Complete left cleft lip
  • Complete left cleft lip and complete left cleft of alveolus
  • Complete right cleft lip
  • Complete right cleft lip and complete right cleft of alveolus
  • Incomplete left cleft lip
  • Incomplete left cleft lip and incomplete left cleft of alveolus
  • Incomplete right cleft lip
  • Incomplete right cleft lip and incomplete right cleft of alveolus
  • Left cleft lip
  • Microbrachycephaly, ptosis, cleft lip syndrome
  • Right cleft lip
  • Verloove Vanhorick Brubakk syndrome

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 Indicator CodePOA Reason 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

  • 749.10 - Cleft lip NOS (Approximate Flag)
  • 749.11 - Unilat cleft lip-compl (Approximate Flag)
  • 749.12 - Unilat cleft lip-imcompl (Approximate Flag)

Code Classification

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

Code History

  • FY 2016 - New Code, effective from 10/1/2015 through 9/30/2016
    (First year ICD-10-CM implemented into the HIPAA code set)
  • FY 2017 - No Change, effective from 10/1/2016 through 9/30/2017
  • FY 2018 - No Change, effective from 10/1/2017 through 9/30/2018
  • FY 2019 - No Change, effective from 10/1/2018 through 9/30/2019
  • FY 2020 - No Change, effective from 10/1/2019 through 9/30/2020

Information for Patients


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]