e-mail Print Share

ICD Reporting on ADA 2012 Form


When required to do so, a dental claim submitter must report an appropriate ICD diagnostic code along with the correct CDT code for the service performed.  

The meaning of “appropriate” in relation to diagnostic codes may vary, but two conditions always apply: 

  • The diagnostic code must be valid, i.e., one that is current for the date of service
  • The diagnostic code should be relevant and specific enough to provide a rationale for the service reported  

If filing electronically, you may be able to use a state Medicaid web portal for filing dental claims electronically.  In-office dental billing systems in current deployment may require upgrades to support diagnostic code reporting. 

The ADA 2012 Dental Claim Form can accommodate ICD diagnostic codes. However, due to space constraints, the diagnostic codes themselves are not reported on the service line item in the same manner as procedure codes.

Here’s how to do it: 

Locate Items 34 and 34a on the ADA 2012 claim form.  They are near the bottom of the "Record of Services Provided" section of the form and slightly to the left of center. 

  1. Take note of Item 34a. In Item 34a, there are four lines labeled “A,” “B,” “C,” and “D.” Up to four diagnoses may be reported on these lines in Item 34a. 
  2. Before doing that, however, the submitter must indicate the source of the diagnostic codes used to report all diagnoses.  For now, we are using ICD-9-CM.  Indicate this by entering “B” in Item 34. 
  3. Enter the appropriate ICD-9-CM code for the PRIMARY diagnosis on line “A.” This diagnosis and its corresponding ICD-9-CM code provide supporting rationale for all reported services performed in connection with it. 
  4. If there is a second diagnosis that requires services in addition to those associated with the primary diagnosis, enter the ICD-9-CM code for that diagnosis on line “B.”
  5. If in the unlikely event there is a need to report a third or even a fourth diagnosis, enter those ICD-9 codes on lines “C” and “D,” respectively.
  6. Next, look at the Record of Services Provided, the table with ten lines divided by ten columns located about halfway down the form. 
  7. Enter the details of each service provided in the normal manner, leaving out 29a “Diag. Pointer” for now.
  8. To link any of services reported with its supporting diagnosis, a submitter must enter a “diagnostic pointer” in Item 29a, immediately to the right of the procedure code reported in Item 29.
  9. A diagnostic pointer is a block capital letter, A, B, C, or D, referencing the code entered on the corresponding line in Item 34a. Enter each pointer as appropriate in item 29 for each service where a diagnosis is required.

To sum up:

  • Enter procedure information in the normal manner, save for Item 29a.
  • Item 34 on the 2012 ADA Dental Claim Form is used to identify the source of the diagnosis codes listed in Item 34a.
    • ICD-9-CM is the current source of diagnosis codes and is identified by the letter “B”
    • On or after October 1, 2015, use of ICD-10-CM will be required and claim submitters will need to enter “AB” in Item 34
  • Enter the primary diagnosis on line A in Item 34a
    • If necessary, enter a second diagnosis on line B
    • Enter third and fourth diagnoses on lines C and D, but again, only if necessary
  • On each service line where it is required to do so, enter a “pointer” in Item 29a referencing the diagnostic code entered on the corresponding line in Item 34a.
    • Each pointer is a block capital letter, A, B, C, or D, and references a diagnosis entered on the corresponding line in Item 34a
    • For example, if the ICD-9-CM code "V72.2 Dental examination" is the primary diagnosis entered on line A, then an “A” is entered in Item 29a for all service lines connected with that diagnostic code

Comprehensive ADA 2012 Claim Form completion instructions are also available here

Your state Medicaid organization may have additional instructions available on their website.



American Dental Association
Department of Dental Informatics
Phone: 312.440.2500
Email: EHR@ada.org
ADA business hours are 8 a.m. to 5 p.m. U.S. Central Time.