For pulmonology, the focus of this revision is CPAP management shifting from volume to quality.
The home CPAP guidance fee 2 lost 10 points from its base, and a 15-point adherence add-on was created in its place. Clinics with good adherence reach 255 points, above the pre-revision level; those without sit at 240, a net decrease. And patients with insufficient use can no longer be billed at all.
1. What changed
| Item | Change | Old → New | Impact |
|---|---|---|---|
| Home CPAP guidance fee 2 | Base reduced. Patients averaging under one hour of use per day in every one of the past three months can no longer be billed | 250 → 240 pts (verify) | High |
| Adherence add-on (new) | Requires monitoring-capable devices and at least 40% of managed months over the past three months having 20+ days of 4+ hours of use | New: 15 pts (240+15 = 255, above the pre-revision level) (verify) | High |
| CPAP coverage criteria revised | AHI threshold eased from 20 to 15 (the proviso threshold moved from AHI 40 to 30) | — | Medium |
| Asthma management fee | Removed from the bundle under lifestyle disease management fee (II); now concurrently billable | — (verify) | Medium |
| Home oxygen therapy, high-flow therapy | No specialty-specific changes identified | — (verify) | Low |
| COPD | No COPD-specific additions or increases identified | — | Low |
2. What it means for the practice
Adherence management has become revenue management.
Three responses:
(1) Move to remote-monitoring-capable devices and build data extraction. The requirement is "at least 40% of managed months over the past three months with 20+ days of 4+ hours of use." That can only be judged if device data is ingested and aggregated month by month. A device that emits data is not enough if there is no way to aggregate it — you cannot even decide whether to file.
(2) Intervene early with low-use patients. Leaving them alone does not only erode the add-on requirement; the patient themselves drops out of billability once three consecutive months average under an hour a day. Mask refitting, motivational interviewing, and follow-up calls need to be triggered by data, early.
(3) Define discontinuation criteria. Without an internal rule on when to stop or switch, you accumulate patients who cannot meet the requirement.
On the other side, easing the threshold to AHI 15 is a tailwind. Mild-to-moderate sleep apnea patients become eligible, and a clean internal pathway from home sleep testing through PSG to initiation lets volume offset the lower unit price.
For asthma patients with comorbid lifestyle disease, the asthma management fee left the bundle under fee (II) and is now concurrently billable. Billing logic needs revisiting.
3. Practical checklist
- Are your CPAP devices remote-monitoring capable, and can you extract data monthly?
- Can you calculate the share of managed months with 20+ days of 4+ hours of use over the past three months?
- Can you identify patients averaging under one hour per day for three consecutive months?
- Is there a pathway (home test → PSG → initiation) for patients with AHI 15–20?
- Have billing system settings been updated for asthma management alongside fee (II)?
4. Where an AI-native EMR fits — feature by feature
Once CPAP evaluation is tied to actual usage, what you do with device data becomes a management question. Here is how Pottech's AI-native EMR helps, feature by feature.
Feature 1: External integration and APIs — ingest CPAP data continuously
An OAuth2 gateway, MCP server, and HAPI FHIR support allow integration with external systems and devices.
The adherence add-on is a requirement you can only assess once device data is ingested and aggregated by month. Forty percent of managed months over the past three — if you cannot produce that number, you cannot tell whether you are eligible to file. Device integration became a precondition for billing in this specialty in 2026.
Feature 2: Patient PHR app integration — act before usage falls
Prescription OCR capture, medication reminders, appointment booking, LINE login, and push notifications.
Leaving a low-use patient until their next visit can cost you the requirement over those three months. A channel that delivers usage feedback and reminders to the patient supports both the add-on and retention. Once adherence is the metric, having a way to reach patients is part of meeting the requirement.
Feature 3: Management analytics dashboard — treat adherence as a management metric
Visit volumes, revenue per patient, and monthly trends are aggregated and visualized automatically.
The metric shifted from "CPAP patients started" to "share of patients with good adherence." Counting initiations tells you nothing about whether the add-on is being earned. Tracking requirement attainment monthly is the foundation for both maintaining the filing and improving on it.
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
- Credo Medical, "Revisions to the home CPAP guidance fee" https://www.credo-m.co.jp/column/detail/hosyu/25383/
- med-cpa, "Revisions to lifestyle disease management fees" https://med-cpa.jp/hoshu-13/
- Tokyo Association of Medical Practitioners, "FY2026 revision: Chuikyo report (excerpt)" https://www.hokeni.org/docs/2026021200012/