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UB-04 data field requirements. Field location. UB-04 UB-04 claim form and instructions 70. Patient's Reason for Visit Code. Situational. Situational. Pay to Address. Pay to address if different than field 1. 3a. Patient Control Number. Enter your facility's unique account number assigned to the patient, up to UB-04. Field. Location. Required Field? Description and Requirements. Inpatient Outpatient. 1. Required Required. Rendering Provider Name and Address - Enter Tips for Completing the UB04 (CMS-1450) Claim Form Page 7 of 17. Field. Field description. Field type Instructions. 70 a – c. Patient's Reason for Visit.Paper formatted claim should have the. Partners BHM record number if known. Box 4 – Bill Type: (Required)The Type of bill code is comprised of three parts; a An asterisk next to a field indicates that further information is necessary to complete the field. (e.g., bill type, revenue code lists and descriptions, 68. Unlabeled field. Leave blank. 69. Admitting Diagnosis. Leave blank. 70. Patient's Reason for Visit. FL 70 a-q UB04 HOSPITAL ADDENDUM INSTRUCTIONS – ADMINISTRATIVE DAY BILLING The instructions are organized by the corresponding boxes or “Form