A child is diagnosed with unilateral cleft lip with cleft soft palate. What are the appropriate diagnosis codes to report using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) and International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)? What are the correct codes to report that the patient’s cleft lip and/or palate has been repaired?

A diagnosis of unilateral cleft lip with cleft soft palate is reported with ICD-9-CM code 749.22, cleft palate with cleft lip, unilateral, incomplete. ICD-9-CM codes for cleft lip and cleft palate include individual codes for cleft lip (749.10–749.14) and cleft palate (749.00–749.04), as well as combination codes to report cleft lip with cleft palate (749.20–749.25). Cleft uvula is reported as an incomplete unilateral cleft palate (749.02).

Code V13.64 is used to report personal history of (corrected) congenital malformations of eye,...

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