ADA Dental Claim Form Completion Instructions
Version 2019 © American Dental Association
Page 11 of 16
Completion Instructions Date: 2022Feb11
applicable to the dental procedure. List the primary diagnosis pointer first.
29b Quantity: Enter the number of times (01-99) the procedure identified in Item 29 is delivered to the
patient on the date of service shown in Item 24. The default value is “01.”
30.
Description: Provide a brief description of the service provided (e.g., abbreviation of the
procedure code’s nomenclature).
31.
Fee: Report the dentist’s full fee for the procedure. Resolution 44-2009 Statement on Reporting
Fees on Dental Claims adopted by the ADA House of Delegates, as follows, provides guidance
on the appropriate entry for this item.
Statement on Reporting Fees on Dental Claims
1)
A full fee is the fee for a service that is set by the dentist, which reflects the costs of
providing the procedure and the value of the dentist’s professional judgment.
2)
A contractual relationship does not change the dentist’s full fee.
3)
It is always appropriate to report the full fee for each service reported to a third-party
payer.
(Note: Item 31 above is the last of the repeating ‘service line’ items.)
31a Other Fee(s): When other charges applicable to dental services provided must be reported, enter
the amount here. Charges may include state tax and other charges imposed by regulatory
bodies.
32.
Total Fee: The sum of all fees from lines in Item #31, plus any fee(s) entered in Item #31a
33.
Missing Teeth Information: Mark an “X” on the number of the missing tooth – for identifying
missing permanent dentition only. Report missing teeth when pertinent to Periodontal,
Prosthodontic (fixed and removable), or Implant Services procedures on a particular claim
NOTE: Numbers marked are based on tooth morphology, not anatomic position.
34.
Diagnosis Code List Qualifier: Enter the appropriate code to identify the diagnosis code source:
AB = ICD-10-CM
34a Diagnosis Code(s): Enter up to four applicable diagnosis codes after each letter (A. – D.). The
primary diagnosis code is entered adjacent to the letter “A.”
NOTE: #34 and #34a are required when a) the diagnosis may have an impact on the
adjudication of the claim in cases where specific dental procedures may
minimize the risks associated with the connection between the patient’s oral
and systemic health conditions; or b) when required by state regulation (e.g.,
Medicaid) or third-party payer contract provisions.
Detailed guidance on reporting ICD-10-CM diagnosis codes is posted on the
ADA Dental Claim Form web page –
ICD Reporting on ADA Dental Claim Form
35.
Remarks: This space may be used to convey additional information for a procedure code that
requires a report, or for multiple supernumerary teeth. It can also be used to convey additional
information you believe is necessary for the payer to process the claim (e.g., for a secondary
claim, the amount the primary carrier paid).
Remarks should be concise and pertinent to the claim submission. Claimants should note that an
entry in “Remarks” may prompt review by a person as part of claim adjudication, which may affect