The headline change for cardiology is the new heart failure readmission prevention fee. It comes in three tiers — multidisciplinary evaluation during acute inpatient care (tier 1), post-discharge outpatient follow-up (tier 2), and ongoing management by community primary care physicians (tier 3) — backing seamless heart failure management with fee schedule support.
For a community cardiology clinic, tier 3 is the revenue opportunity.
1. What changed
| Item | Change | Old → New | Impact |
|---|---|---|---|
| Heart failure readmission prevention fee (new) | Tier 1 multidisciplinary evaluation during acute admission; tier 2 post-discharge outpatient follow-up; tier 3 ongoing management in the community. Monthly, limited to one year from the index date (tiers 2 and 3) | New: tier 1 1,000 pts (once during admission); tier 2 700 pts (visits 1–6), 225 pts (7+); tier 3 400 pts (1–6), 225 pts (7+) (verify) | High |
| Facility criteria for tier 3 (clinics) | A designated physician with 3+ years of heart failure guidance experience plus nursing staff. The registered dietitian may be supplied via a nutrition care station or partner institution | — | Medium |
| Mutual exclusions | Cannot be billed alongside the specific disease care management fee, outpatient nutrition guidance fee, or same-day cardiac rehabilitation | — | High |
| Community comprehensive care criteria expanded | Chronic heart failure added to eligible conditions (with care need) | — (verify) | Medium |
| Home CPAP guidance fee 2 | Base reduced by 10 pts, plus a new adherence add-on. Patients with insufficient use can no longer be billed | 250 → 240 pts; adherence add-on 15 pts (240+15 = 255) (verify) | Medium |
| Cardiac rehabilitation fee | No cardiac-rehab-specific point changes identified. Impact comes from general rehabilitation changes (two-tier early rehab add-on, 90/100 reduction for non-mobilizing rehab) | — (verify) | Low |
2. What it means for the practice
Tier 3 is 400 points × 6 months plus 225 points thereafter — close to 3,000 points per patient over a year. Two cautions apply.
(1) Mutual exclusions must be worked out. It cannot be billed alongside the specific disease care management fee or the outpatient nutrition guidance fee. For heart failure patients currently billed under the specific disease care management fee, simulate which is better, patient by patient. Patients on the lifestyle disease management fee need the same treatment.
(2) Multidisciplinary staffing is the key to filing. Beyond a designated physician with three or more years of heart failure guidance experience, nursing staff are required. The registered dietitian may come through a nutrition care station or partner institution, which leaves a path open for clinics that cannot hire one directly.
For CPAP, the structure is 10 points out of the base and 15 points into an add-on. Meet the adherence data requirement — at least 40% of managed months in the past three months having 20 or more days of 4+ hours of use — and the total is 255 points, above the pre-revision 250. Miss it and you are at 240, a net decrease. Remote monitoring and outpatient follow-up translate directly into that difference.
Chronic heart failure was added to the community comprehensive care criteria, widening billing opportunities in the primary care role.
3. Practical checklist
- Do you meet the facility criteria for tier 3 (physician experience, nursing staff)?
- Have you secured a registered dietitian partner (nutrition care station or otherwise)?
- Have you compared tier 3 against the specific disease care management fee for current heart failure patients?
- Is there a care pathway with acute hospitals for the tier 2 → tier 3 handoff?
- Can you aggregate CPAP adherence (share of months with 20+ days of 4+ hours of use)?
4. Where an AI-native EMR fits — feature by feature
For cardiology, almost everything in 2026 comes down to whether you can show, with data, that a requirement was met — testing intervals, CPAP usage, multidisciplinary records. Here is how Pottech's AI-native EMR takes on that burden, feature by feature.
Feature 1: External integration and APIs — bring CPAP data into the record
An OAuth2 gateway, MCP server, and HAPI FHIR support allow integration with external systems and devices.
The adherence add-on requires use of remote-monitoring-capable devices and an outcome-linked threshold: at least 40% of managed months over the past three months with 20 or more days of 4+ hours of use. That requirement only exists if device data can be ingested and aggregated continuously. Device integration and data visibility are the billing eligibility.
Feature 2: Charting and orders — make multidisciplinary records consistent
AI generates SOAP notes from the consultation audio, and set orders enter tests and prescriptions in one action.
The heart failure fee sets multidisciplinary staffing — physician, nurse, registered dietitian — as a facility criterion. In multidisciplinary management, the record of who guided the patient, when, and on what is the evidence behind the claim. When granularity varies by profession, proving compliance becomes hard; standardizing the record format matters more than the time saved.
Feature 3: Billing and claims management — enforce exclusions and deadlines mechanically
The automatic billing engine checks bundling, mutual exclusions, and frequency limits.
Tier 3 combines a one-year limit from the index date, a step-down from 400 to 225 points after six visits, and exclusions against the specific disease care management and outpatient nutrition guidance fees. Managing that combination from memory is not realistic. Having the system determine visit counts and exclusions is what prevents rejected claims.
Also review what applies to every specialty
Consultation fees, the inflation add-on, the wage increase evaluation fee, and the six-month blood testing requirement under lifestyle disease management fee (I) are collected in "what applies to every specialty."
Sources (principal)
- MHLW, "About the FY2026 Fee Schedule Revision" https://www.mhlw.go.jp/stf/newpage_67729.html
- Sasaki Research Institute, "The new heart failure readmission prevention fee" https://www.sasakigp.co.jp/column/10029870
- Credo Medical, "Revisions to the home CPAP guidance fee" https://www.credo-m.co.jp/column/detail/hosyu/25383/
- med-cpa, "Revisions to community comprehensive care add-ons" https://med-cpa.jp/hoshu-14/