Personal history of (corrected) cleft lip and palate

This code indicates that a patient has a past medical history of a cleft lip and/or palate that has been surgically repaired or otherwise corrected. It signifies that the congenital anomaly is no longer an active problem but remains relevant to the patient's overall health record. This history can impact future medical or dental care.

Use this code when documenting a patient's medical history for follow-up care related to their corrected cleft lip and palate, such as speech therapy, dental evaluations, or psychological support. It is also appropriate for general medical visits where the past history of this condition is pertinent to the patient's current health status or treatment plan.

• This is a history code; it should not be used for active, uncorrected cleft lip or palate.
• Always sequence this code as a secondary diagnosis, following any current, acute conditions.
• Consider additional codes for any residual complications or ongoing issues directly related to the corrected cleft, such as speech impediments or dental malocclusion.