CPAP Enhanced Management System Addition 2026: Points, Facility Standards and Billing Rules

Questions we often hear from directors, office managers and medical clerks at clinics that provide CPAP therapy for sleep apnea: "Can our clinic file for the CPAP enhanced management system addition?", "How is the 40% usage standard counted?", and "Are there patients for whom we must not bill management fee 2?" This article organizes the points, billing rules, facility standards and notification, based on the FY2026 fee schedule (MHLW Public Notice No. 69), the interpretive notice (Hoi-hatsu 0305 No. 6) and the facility standards notice for special medical treatment fees (Hoi-hatsu 0305 No. 8).

Disclaimer: This article is general information based on public documents as of November 3, 2026. The official notices of the Ministry of Health, Labour and Welfare (MHLW) and the guidance of your regional Bureau of Health and Welfare are authoritative. Always confirm billing and notification decisions against the latest original texts and your regional bureau.

Overview: C107-2 and related points

Guidance for patients receiving home CPAP (continuous positive airway pressure) therapy is evaluated under "C107-2 Home CPAP Therapy Management Fee." The points in the notice are as follows.

Note that the enhanced management system addition can be added to management fee 2 only (Note 2 of the notice).

Eligible patients: fee 1 vs. fee 2

The interpretive notice distinguishes them as follows.

• Fee 1: Chronic heart failure patients with NYHA class III or higher, Cheyne-Stokes respiration during sleep and an apnea-hypopnea index (AHI) of 20 or more on polysomnography, who still had an AHI above 15 under CPAP and were placed on ASV therapy (both conditions must apply)
• Fee 2: Any of the following (a)–(c)
  • (a) Heart failure patients as above, not covered by fee 1, who receive ASV therapy
  • (b) Heart failure patients who must continue ASV therapy while heeding the ASV appropriate-use statement of the Japanese Circulation Society and the Japanese Heart Failure Society
  • (c) Patients meeting all of (i)–(iii) (if AHI is 30 or more, (ii) alone is enough)
    • (i) AHI (apneas plus hypopneas per hour) of 15 or more
    • (ii) Strong symptoms such as daytime sleepiness or morning headache that interfere with daily life
    • (iii) On polysomnography, fragmented sleep and markedly reduced or absent deep sleep due to frequent apneas, which normalize under CPAP

Common rules in the notice:

• Treatment status is evaluated for up to 2 months after the start; only cases judged suitable to continue remain billable
• When billing the management fee, the CPAP device is loaned to the patient by the medical institution

When not to bill management fee 2 (usage check)

Interpretive notice item (6) covers SAS patients meeting condition (c) who are on CPAP. Using equipment that can monitor usage, if the average daily usage was under 1 hour in every one of the three months before the month of management, do not bill the management fee.

• Patients within 3 months of starting CPAP are exempt from this rule
• Even then, the notice states that the home treatment materials addition can still be billed

Facility standards for the enhanced management system addition (Note 2)

The facility standards notice (Section 16-7) requires two things.

1. Monitoring system: For all non-inpatients receiving CPAP management at the institution who are eligible for fee 2, usage and AHI are regularly monitored with equipment capable of monitoring them
2. Management results: Within the most recent 3 months, the share of the total patient-months of CPAP management in which the device was used 4 hours or more on 20 or more days is 40% or higher

How the 40% standard is counted (illustration)

Form 20-12 asks for three figures.

The numbers above are hypothetical, only to show the calculation; the actual judgment uses the form and your last three months of results.

Chart documentation

Interpretive notice item (7) states that for the addition, regardless of whether the management fee is billed, usage and AHI must be monitored for all CPAP-managed patients and the average daily CPAP usage entered in the medical record. Note that monitoring covers patients not billed under this fee as well.

Notification

• Use Form 20-12 of Attachment 2
• The form for the remote monitoring addition is specified separately in the same notice (Attachment 2-2)

Remote monitoring addition (Note 3)

For fee-2 patients on CPAP, when usage and AHI are regularly monitored via information and communication equipment from the month after the previous visit to the month before the current visit, and necessary guidance is given, bill 150 points × the number of months (up to 2) at the visit. Main requirements from interpretive notice item (8):

• With patient consent, create a care plan combining in-person visits and monitoring (including emergency response)
• In the billing month, record the clinical findings from monitoring and any guidance given in the medical record
• Guidance is given by phone or video call; when using communication devices, follow the online care guideline
• The cost of this care is included in the addition

The facility standard requires, when giving guidance by video call, a system for care in line with the online care guideline.

Management via communication devices (Note 4: 218 points)

Under Note 4, when management that would be billed as fee 2 is provided via information and communication devices, bill 218 points instead of 240. The notice specifies:

• Targets are patients meeting condition (c) who are on CPAP with a diagnosis of obstructive sleep apnea
• Do it only after confirming in person that CPAP has improved symptoms such as sleepiness and snoring
• Check the same CPAP management data as in person
• Switch to in-person care promptly if symptoms worsen
• Record the first-visit date and the date of in-person confirmation in the chart and the receipt abstract field
• The facility standard is simply having the notification for care via information and communication devices; no separate notification for Note 4 is needed

For setting up online care, see Starting Online Care 2026.

Practical checklist

• Do you have a list of CPAP-managed patients and a system to see usage and AHI?
• Can you tally months with 4+ hours on 20+ days against total patient-months for the last 3 months?
• Is average daily CPAP usage recorded in the chart?
• Do you check patients whose average daily use was under 1 hour in all of the previous three months (excluding the first 3 months) before billing fee 2?
• Have you submitted Form 20-12 and confirmed with your regional bureau?
• If using the remote monitoring addition or Note 4, are the care plan and chart items in place?

For a broader review to prevent missed or wrong claims, see the Billing Omission Checklist.

FAQ

Q. Can the enhanced management system addition be billed with fee 1? A. No. Note 2 of the notice applies to fee 2 only.

Q. Is usage monitoring needed for patients not billed under the fee? A. Notice item (7) covers all patients under CPAP management, regardless of whether the fee is billed.

Q. Which form is used for notification? A. Form 20-12 of Attachment 2.

Summary

• Fee 2 is 240 points; the enhanced management system addition is 15 points, added to fee 2 only
• Facility standard: monitoring of all patients, and 40% or more of patient-months in the last 3 months with 4+ hours of use on 20+ days
• Do not bill fee 2 if average daily usage was under 1 hour in each of the previous three months (except within 3 months of starting)
• Remote monitoring addition is 150 points × months (up to 2); management via communication devices is 218 points

For the broader clinic workflow and EMR selection in respiratory and allergy care, see EMRs for Respiratory and Allergy Clinics.

Contact Pottech

Pottech supports clinics with EMR and claims workflow efficiency. For questions on billing requirements or on feeding usage data into charts and claim checks, please reach out via Contact.

References

• MHLW, "Partial Revision of the Fee Schedule for Medical Treatment" (FY2026 MHLW Public Notice No. 69), medical fee schedule C107-2, C165, C171-2. https://www.mhlw.go.jp/content/12400000/001686842.pdf
• MHLW Health Insurance Bureau, "Interpretive Notice on the Revision of the Fee Schedule" (Hoi-hatsu 0305 No. 6, March 5, 2026), Attachment 1, C107-2. https://www.mhlw.go.jp/content/12400000/001757385.pdf
• MHLW Health Insurance Bureau, "Facility Standards for Special Medical Treatment Fees and Notification Procedures" (Hoi-hatsu 0305 No. 8, March 5, 2026), Section 16-7 and Form 20-12 (published by Kanto-Shinetsu Bureau). https://kouseikyoku.mhlw.go.jp/kantoshinetsu/tokkei080305.pdf