For breast surgery, the conclusion is that no significant specialty-specific change was identified; the impact comes from cross-specialty items.
Surgery, biopsy, and imaging are all unchanged, leaving the revision neutral to marginally positive. The one positive element is the +100 points on 3-tesla-or-higher MRI flowing through to breast MRI.
1. What changed
| Item | Change | Old → New | Impact |
|---|---|---|---|
| Breast cancer surgery (K476) | No point change identified (unchanged) | e.g. partial mastectomy (without dissection) 28,210 pts / (with dissection) 42,350 pts; pectoralis-preserving mastectomy and other tiers unchanged; sentinel node biopsy add-on 1: 5,000 pts, add-on 2: 3,000 pts (unchanged, verify) | Low |
| Breast puncture or needle biopsy (D410) | No point change identified (unchanged) | 1 with biopsy needle 690 pts / 2 other 200 pts (unchanged, verify) | Low |
| Breast MRI add-on and MRI base | Breast MRI add-on continues at 100 pts. The +100 pts on 3T-or-higher MRI (1,620 → 1,720 and similar) flows through to breast MRI | Add-on 100 pts (unchanged); E202 base +100 pts (verify) | Medium |
| Mammography and breast ultrasound | No significant change to insurance points identified. Population-based breast cancer screening is a municipal programme priced by contract, outside the fee schedule | — | Low |
| Surgical care assurance add-on eligibility | Covered high-complexity procedures are reportedly centred on GI surgery; whether breast procedures are included requires checking the covered K-code list | — (verify) | Low |
2. What it means for the practice
(1) Facilities with a 3T scanner should check the billing category. The breast MRI add-on stays at 100 points, but the MRI base (E202) gained 100 points at 3 tesla and above. Confirm the category is set correctly.
(2) Screening rates are negotiated separately. Screening — the revenue driver for breast clinics — is a matter of municipal and corporate health insurance contract rates, outside the fee schedule. Price increases reflecting inflation and wage costs have to be pursued with those counterparties. That the revision raised labour costs across the medical sector is usable material in that negotiation.
(3) Hospital breast surgery departments must verify eligibility for the surgical care assurance add-on against primary sources. Covered procedures are reportedly centred on GI surgery, but whether breast procedures appear in the official schedule changes the picture. If they do, the upside is +15% on the surgical fee — which makes this a high-priority check.
(4) Capturing the cross-specialty items is the practical revenue strategy. Screening and post-operative follow-up skew this specialty toward return visits, so the return-side additions accumulate.
3. Practical checklist
- Is the breast MRI billing category (3T+ vs 1.5T) set correctly?
- Have you filed for the breast MRI add-on facility criteria?
- Have you verified against primary sources whether breast procedures appear on the surgical care assurance add-on list?
- Have you prepared to use the revision as material in screening rate negotiations?
- Have you audited for missed sentinel node biopsy add-ons?
- Have you confirmed the inflation add-on and wage increase evaluation fee land on return visit claims?
4. Where an AI-native EMR fits — feature by feature
In a year when insurance points do not move, the pathway from screening into care and the continuity of follow-up decide results. Here is how Pottech's AI-native EMR helps, feature by feature.
Feature 1: Patient PHR app integration — sustain screening and follow-up
Appointment booking, LINE login and push notifications, and medication reminders.
Breast care is a field where "getting the patient back a year later" determines both revenue and clinical quality. Screening reminders, post-operative follow-up timing, adherence to hormone therapy. Delivering these to patients reduces the phone and postcard workload while raising continuation. In a year without upside from the rules, that accumulation is what shows.
Feature 2: Management analytics dashboard — watch conversion from screening
Visit volumes, revenue per patient, and monthly trends are aggregated and visualized automatically.
The metric here is not screening volume alone but the share of screened patients who move into further investigation and treatment. It is also a useful number in rate negotiations: how much downstream work your clinic absorbs. In a year when insurance points are flat, understanding that structure in numbers is worth the effort.
Feature 3: Billing and claims management — close add-on gaps
The automatic billing engine checks bundling, mutual exclusions, and frequency limits.
Sentinel node biopsy add-ons (5,000 and 3,000 pts) and the breast MRI add-on (100 pts) — the less frequent the add-on, the more easily its rules slip from memory. Some items, like the 3T MRI category, only deliver the increase once the setting is updated. Keeping billing logic in the system prevents quiet losses.
Also review what applies to every specialty
For breast surgery, capturing the cross-specialty items is the main source of upside. See "what applies to every specialty."
Sources (principal)
- MHLW, "About the FY2026 Fee Schedule Revision" https://www.mhlw.go.jp/stf/newpage_67729.html
- Knowlety, "K476 breast cancer surgery (FY2026 fee table)" https://knowlety.jp/ika/k476/
- Knowlety, "D410 breast puncture or needle biopsy (FY2026 fee table)" https://knowlety.jp/ika/d410/
- Shirobon, "E202 magnetic resonance imaging (FY2026 fee table)" https://shirobon.net/medicalfee/latest/ika/r08_ika/r08i_ch2/r08i2_pa4/r08i24_sec3/r08i243_E202.html
- Japan Surgical Society, "On the new surgical care assurance add-on in the FY2026 revision" https://www.jssoc.or.jp/modules/info/index.php?content_id=652