The lifestyle disease management fee — the backbone of outpatient revenue for internal medicine clinics — kept its base points unchanged: 610–760 for (I), 333 for (II). On the numbers alone, nothing happened.
What actually changed is the evaluation structure. Clinics now submit data, are compared against peers on outcomes, and receive different add-on amounts depending on whether they land in the top 20%, the top 50%, or elsewhere. The question shifted from "can we bill this?" to "at which tier?"
1. What changed
| Item | Change | Old → New | Impact |
|---|---|---|---|
| Lifestyle disease management fee (I)(II) | Base points unchanged. (I) now requires blood testing at least once every six months. Patient signature on the care plan abolished | (I) 610/660/760 pts, (II) 333 pts (unchanged, verify) | High |
| Narrower bundling for (II) | Concurrently billable management fees expanded from 16 to 37 items; drug therapy monitoring and asthma management fees removed from the bundle | — (fee-for-service upside) | Medium |
| Enhanced management add-on (new) | Data submission to the outpatient care survey plus relative outcome scoring. Top 20% = tier 1, top 50% = tier 2, otherwise tier 3. Replaces the outpatient data submission add-on (50 pts) | New: 30 / 20 / 10 pts (verify) | High |
| Community comprehensive care fee and add-on restructured | Dementia-specific versions merged in. Eligible patients now include those with any one of dyslipidemia, hypertension, diabetes, chronic heart failure, or CKD plus long-term care need | Fee 1: 1,660 → 1,661 pts; add-ons 28/21 pts unchanged (verify) | Medium |
| Outpatient data submission add-on (new, for community comprehensive care) | Evaluates ongoing submission of claims and clinical data | New: 10 pts/month (verify) | Low |
| Home care capacity evaluation | Increase to the home care capacity add-on; new pharmacist joint home visit guidance fee | Home care capacity add-on 800 pts (+400, single-building single patient); pharmacist joint guidance 300 pts (verify) | Medium |
There is a transitional measure: through 31 March 2027, clinics are treated as tier 1 for the enhanced management add-on (verify). Whether you can accumulate results during that window determines your tier afterwards.
2. What it means for the practice
The enhanced management add-on requires filing (twice yearly, in May and November) and data submission. For a clinic that has not started, the realistic path is to secure tier 3 (10 pts) first, then raise testing rates and guideline adherence to aim higher. The gap between the top 20% and everyone else is 20 points. For a clinic billing 300 eligible patients a month, that is 6,000 points — 60,000 yen a month, 720,000 yen a year.
The six-month blood test requirement for (I) translates directly into billing failures and claim rejections. In a clinic managing several hundred patients with hypertension or dyslipidemia, tracking every last test date by memory is not realistic. This is a requirement that belongs in an automated order reminder.
Abolishing the care plan signature is an opportunity to shorten front-desk workflow. Preparation, delivery, explanation, and consent remain mandatory, so decide anew how consent will be recorded.
The expanded community comprehensive care criteria — one condition plus care need — increase the eligible population. Re-check your coordination with care managers and your ability to capture long-term care insurance status, and align your filing strategy with the primary care function reporting system.
3. Practical checklist
- Is the filing window for the enhanced management add-on (May, November) on the annual calendar?
- Can you pull the last blood test date for every patient billed under fee (I)?
- Have billing system settings been updated for the narrower bundling under (II)?
- Have you redefined how consent to the care plan is recorded?
- With the expanded criteria, can you capture long-term care certification status?
4. Where an AI-native EMR fits — feature by feature
For internal medicine, 2026 is the year the question became "at which tier can we bill?" rather than "can we bill?" The tier is decided by data that accumulates through everyday practice. Here is how Pottech's AI-native EMR supports that, feature by feature.
Feature 1: Billing and claims management — manage the six-month test as a deadline
The automatic billing engine checks bundling, mutual exclusions, and frequency limits, and determines billing eligibility.
A missed blood test means fee (I) simply cannot be billed. Being able to pull "patients whose last blood test was more than five months ago" from order history is revenue protection, directly. The expansion of concurrently billable items under (II) from 16 to 37 is the same story: without automated eligibility checks, it becomes a source of unbilled work.
Feature 2: Management analytics dashboard — read your own tier
Visit volumes, revenue per patient, and monthly trends are aggregated and visualized automatically.
The enhanced management add-on is scored relatively. Without knowing your own numbers, you cannot even tell which tier is within reach. Tracking billing rates, testing rates, and blood pressure / HbA1c control monthly is the precondition for building a record during the transitional period through March 2027.
Feature 3: Charting and orders — make care plans and guidance records consistent
AI generates SOAP notes from the consultation audio, and set orders enter tests and prescriptions in one action.
The signature is gone, but explanation and consent still have to be evidenced. When record formats vary by physician, proving that a requirement was met becomes difficult. Templates and voice input that standardize the record are as much about audit readiness as about time saved.
Also review what applies to every specialty
Consultation fees, the inflation add-on, the wage increase evaluation fee, the electronic clinical information coordination add-on, and the increase in patient cost-sharing on long-listed drugs are collected in "what applies to every specialty." The 30% My Number card usage requirement matters most for high-volume specialties like internal medicine.
Sources (principal)
- MHLW, "About the FY2026 Fee Schedule Revision" https://www.mhlw.go.jp/stf/newpage_67729.html
- med-cpa, "Revisions to lifestyle disease management fees" https://med-cpa.jp/hoshu-13/
- med-cpa, "Revisions to community comprehensive care add-ons" https://med-cpa.jp/hoshu-14/
- Sasaki Research Institute, "Lifestyle disease management and the enhanced management add-on" https://www.sasakigp.co.jp/column/10029734
- Tokyo Association of Medical Practitioners, "FY2026 revision: Chuikyo report (excerpt)" https://www.hokeni.org/docs/2026021200012/