Learn about Undifferentiated Connective Tissue Disease (UCTD) diagnosis, clinical documentation, and medical coding. Find information on UCTD symptoms, diagnostic criteria, and ICD-10 codes for accurate healthcare record keeping and billing. This resource covers best practices for documenting UCTD in medical charts, including key clinical features and relevant laboratory tests. Explore the connection between UCTD and other connective tissue diseases like lupus and rheumatoid arthritis. Understand the importance of proper coding for UCTD to ensure appropriate reimbursement and facilitate research on this complex condition.
Also known as
Undifferentiated connective tissue disease
Systemic autoimmune disorder with features of multiple connective tissue diseases.
Overlap connective tissue disorder
Features of multiple defined connective tissue diseases present simultaneously.
Systemic lupus erythematosus
Autoimmune disease affecting multiple organ systems with varied manifestations.
Inflammatory polyarthropathies
Joint inflammation often associated with autoimmune and connective tissue disorders.
Follow this step-by-step guide to choose the correct ICD-10 code.
Does patient meet criteria for any specific CTD?
Yes
Code the specific CTD. Do NOT code M35.9
No
Signs/symptoms suggestive of CTD?
When to use each related code
| Description |
|---|
| Undifferentiated signs of connective tissue disease |
| Mixed connective tissue disease |
| Overlap connective tissue disease |
Using M35.9 (Undifferentiated connective tissue disorder) without sufficient documentation to support a more specific diagnosis, leading to inaccurate reporting.
Misdiagnosis due to overlapping symptoms with other rheumatic diseases, like lupus or RA, impacting coding accuracy and reimbursement.
Insufficient clinical evidence, like lab results or exam findings, to justify UCTD diagnosis, increasing audit risk and claim denials.
Patient presents with a constellation of symptoms suggestive of Undifferentiated Connective Tissue Disease (UCTD). The patient reports experiencing arthralgia, myalgia, fatigue, and Raynaud's phenomenon. On physical examination, the patient exhibited mild joint tenderness and swelling, but no overt synovitis. Laboratory evaluation reveals elevated inflammatory markers, including an elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). Antinuclear antibody (ANA) testing is positive with a speckled pattern, but specific antibodies for systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), scleroderma, Sjogren's syndrome, and polymyositis are negative. The patient's symptoms and laboratory findings do not fulfill the classification criteria for any specific defined connective tissue disease, leading to the diagnosis of UCTD. Differential diagnoses considered include early-stage connective tissue disease, fibromyalgia, and chronic fatigue syndrome. The patient's symptoms are currently impacting their activities of daily living (ADLs). The treatment plan includes patient education on UCTD, including its prognosis and potential progression to a defined connective tissue disease. Nonsteroidal anti-inflammatory drugs (NSAIDs) are prescribed for symptomatic management of arthralgia and myalgia. Close monitoring for the development of specific connective tissue disease features is warranted, with regular follow-up appointments scheduled for reassessment and potential adjustment of the treatment plan. ICD-10 code M35.9, Unspecified connective tissue disease, is applied. Further investigations may be considered depending on the evolution of the patient's clinical picture.