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Research on Telemedicine Reimbursement

How Do Medical Billing Systems Process Medical Fees?

A medical billing system, commonly called a receipt computer (rececon) in Japan, is used to calculate medical fees and generate health insurance claims. Its processing is based in part on various master files provided through the Ministry of Health, Labour and Welfare’s Medical Fee Information Service.

The Medical Procedure Master contains not only procedure codes and fee points, but also numerous machine-readable attributes, including inpatient/outpatient applicability, DPC applicability, classifications related to medical management fees, effective start and end dates, and chapter, part, and section numbers in the medical fee schedule.

For example, under the FY2026 fee schedule, B005-11 “Remote Collaborative Care Fee (Inpatient Care)” is registered under procedure code 113715010 at 900 points, with a DPC applicability code of 1.

The Master File Specification defines DPC applicability code 1 as a “medical procedure that can be billed in the fee-for-service portion of a DPC claim.”

This means that a medical billing system can use not only information such as “Remote Collaborative Care Fee = 900 points,” but also machine-readable data indicating how the procedure can be handled within a DPC claim.

Ministry of Health,Labour and WelfareMedical Fee Master DataProcedure CodesFee PointsDPC ApplicabilityInpatient / Outpatient ApplicabilityOther AttributesMedical Billing System(Rececon)Fee Calculation & ChecksClaim GenerationElectronic ClaimUses master data

However, the master data provided by the Ministry of Health, Labour and Welfare alone cannot automatically determine whether every billing requirement has been satisfied.

For example, billing the Remote Collaborative Care Fee also depends on facts such as whether the patient meets the eligibility criteria, whether patient consent was obtained, whether clinical information was provided in advance, and whether collaborative care with a physician at another medical institution was actually performed.

These conditions cannot be determined solely from fields such as the fee points or DPC applicability code in the Medical Procedure Master. In practice, medical billing systems generate claims by combining master data and electronic claim specifications provided by the Ministry with patient and clinical information entered by the medical institution and billing and validation functions implemented in the system.

The medical fee master data can therefore be regarded as foundational machine-readable data used by medical billing systems to process medical fees and generate claims.

References

Section titled “References”

  1. Ministry of Health, Labour and Welfare, Health Insurance Bureau, “Medical Fee Information Service — FY2026 Medical Fee Revision”

  2. Ministry of Health, Labour and Welfare, Health Insurance Bureau, “FY2026 Master File Specification”

  3. Ministry of Health, Labour and Welfare, Health Insurance Bureau, “FY2026 Medical Procedure Master”

  4. Ministry of Health, Labour and Welfare, Health Insurance Bureau, “Recording Specifications for Online or Optical Disk Claims (DPC)”