Ophthalmology is one of the hardest-hit specialties in this revision.
The short-stay surgery basic fee 1 was cut substantially, and a direction to restrict the facility criteria to hospitals was signalled at the draft stage. The policy intent — moving short-stay surgery that does not medically require admission to outpatient — is explicit, backed by data showing that "admission is preferable for business reasons" accounted for 24.0% of admission rationales in cataract surgery.
1. What changed
| Item | Change | Old → New | Impact |
|---|---|---|---|
| Short-stay surgery basic fee 1 (day surgery, cataract and similar) | Substantially reduced, with a signalled direction to restrict facility criteria to hospitals, emphasizing case selection and operational rigour | With anesthesia 1,588 → 795; without 1,359 → 680 (about ▲50%, verify) | High |
| Short-stay surgery basic fee 3 and inpatient cataract | Explicit steer toward moving short-stay surgery that does not medically require admission to outpatient. Cataract surgery to outpatient in principle | Specific points require verification | High |
| Ophthalmology coordination add-on (new) | Created alongside the lifestyle disease management revision. Evaluates coordination where a diabetic patient needs eye care. Billed on the internal medicine side, once per patient per year | New: 60 pts (verify) | Medium (referral upside for ophthalmology) |
| Myopia control treatment testing | With the move into selective treatment, related tests are capped at twice a year and two types per visit | Tighter limits (verify) | Low–Medium |
| Contact lens examination fee | No significant FY2026-specific change identified (current tiers 1–4 appear to continue) | — (verify) | Low |
2. What it means for the practice
(1) Move fully to outpatient day surgery. With fee 1 halved and hospital-only criteria signalled, facilities relying on inpatient or short-stay cataract surgery face a direct hit. Migration to outpatient day surgery, adding operating slots to hold volume, and raising the selective-treatment (multifocal IOL) share are all urgent.
(2) Where admission is retained, document the medical indication. For cases needing general anesthesia, or with dementia or systemic risk, make documenting the medical basis for admission a standing practice. It is essential preparation for claim review.
(3) The internal medicine coordination add-on is a tailwind. The new 60 points (annual) on the internal medicine side encourages eye referrals for diabetic patients. Offering local lifestyle-disease-management clinics a clear diabetic eye record and reply-letter workflow builds a patient pipeline from retinopathy screening through laser and anti-VEGF treatment. Ophthalmology does not bill it — but a referral entry point has been created by policy.
(4) Watch the limits on myopia control testing. The move into selective treatment brought caps of twice a year and two test types per visit.
3. Practical checklist
- Have you assessed migrating cataract cases billed under fee 1 to outpatient day surgery?
- Have you established documentation practice for the medical indication where admission continues?
- Are explanatory materials and price posting in place for selective treatment (multifocal IOL)?
- Have you offered local internal medicine clinics a referral and reply-letter workflow for diabetic retinopathy?
- Are the frequency limits on myopia control testing reflected in the billing system?
- Do you know your operating slot utilization and cases per slot?
4. Where an AI-native EMR fits — feature by feature
In 2026 this specialty is running two migrations at once: inpatient to outpatient, and insurance to selective treatment. Here is how Pottech's AI-native EMR helps, feature by feature.
Feature 1: Billing and claims management — keep insurance and selective treatment separate
The automatic billing engine checks bundling, mutual exclusions, and frequency limits.
Multifocal IOLs under selective treatment require a clean separation between the insured and self-pay portions. Raising the share means doing that calculation more often. The caps introduced on myopia control testing — twice a year, two types per visit — work the same way: frequency management in the system is what prevents rejections.
Feature 2: External integration and APIs — run referrals and replies with internal medicine
An OAuth2 gateway, MCP server, and HAPI FHIR support allow integration with external systems.
The ophthalmology coordination add-on is billed by internal medicine, but billing it requires a reply from ophthalmology. Practices that reliably return replies attract more referrals. Every time a referring internist bills that annual add-on, it means the patient attended eye care. Lowering the friction of coordination raises the ceiling on referral volume.
Feature 3: Management analytics dashboard — track the structural shift in surgery
Visit volumes, revenue per patient, and monthly trends are aggregated and visualized automatically.
Moving from inpatient to outpatient is a change where case counts can stay flat while the revenue structure changes entirely. Revenue per case, selective treatment share, and slot utilization have to be visible separately, or you cannot tell whether the migration is working. In a declining-revenue phase, where you make it back has to be decided with numbers.
Also review what applies to every specialty
Consultation fees, the inflation add-on, the wage increase evaluation fee, and the electronic clinical information coordination add-on 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
- Funai Consulting, "Impact of the 2026 revision on ophthalmology clinics" https://byoin-clinic-keiei.funaisoken.co.jp/blogs/column/ganka-0477
- HOKUTO, "Fee revision draft 1: short-stay surgery basic fee, tightened add-on conditions" https://hokuto.app/post/jdCgwqPUPsNp1EvamUle
- PRRISM, "Direction of the FY2026 revision for short-stay surgery basic fee 3" https://www.prrism.com/newscolumns/10560/
- Maeyamada Jun Shoten, "How lifestyle disease management changes in 2026 (eye and dental coordination, 60 pts)" https://www.maeyamadajun-shoten.com/blog/1030