Supervision Requirements in 2026
Supervision requirements remain a key area of focus for radiology compliance and operations. While supervision has always been a foundational component of clinical operations, the last several years have introduced significant flexibility in how supervision may be provided. What began as a temporary response to the COVID-19 public health emergency (PHE) has now evolved into a more permanent component of Medicare policy.
As of January 1, 2026, organizations must understand not only the supervision requirements themselves, but also how the expanded definition of direct supervision, including virtual presence, continues to impact daily operations.
Defining Supervision Requirements
Supervision requirements for diagnostic imaging services are defined in the Medicare Benefit Policy Manual, Chapter 15, Section 80. There are three levels of supervision for diagnostic tests: general supervision, direct supervision, and personal supervision.
- General supervision means the procedure is performed under the physician’s overall direction without the physician’s presence.
- Direct supervision requires the physician to be immediately available to furnish assistance and direction, which may now be provided virtually via real-time audio-video technology. (More on that in detail below.)
- Personal supervision requires the physician to be present in the room during the procedure.
It is also important to recognize that not all services are subject to these supervision levels. Under the Medicare Physician Fee Schedule (MPFS), services assigned a status indicator of “9” (concept does not apply) are not governed by supervision requirements, as the nature of the service assumes it is performed by the individual who reports it. In these cases, commonly seen with interventional procedures, the expectation is that the provider who performs the service is the one who bills for it, rather than applying supervision rules to assign billing to another provider.
Changes to Direct Supervision
Direct supervision required the physical presence of a physician in the suite or immediately available within the facility. This requirement changed significantly during COVID-19, when the Centers for Medicare & Medicaid Services (CMS) redefined direct supervision under the MPFS to allow the supervising physician to be virtually present using real-time audio-video technology. This change allowed physicians to provide immediate direction and assistance without being physically present in the same location.
What began as a temporary measure has now become part of standard operations. CMS continued to extend and refine this policy through subsequent rulemaking from 2020 through 2025, when it finally implemented a permanent exception.
As of January 1, 2026, the use of real-time audio-video technology to provide direct supervision is now an accepted and ongoing method of meeting supervision requirements when appropriate. CMS maintains that the supervising physician must still be immediately available, but this availability may be achieved through interactive, real-time audio-video communication rather than physical presence.
CMS also clarified that the physician does not need to continuously observe the procedure via video but must be immediately available to engage if needed. It is important to remember that supervision requirements represent a minimum standard and not necessarily a best-practice recommendation.
New Supervision Policies for NPs, PAs, and APPs in 2026
CMS finalized several important supervision policies in prior rulemaking that remain in effect for 2026. Nurse practitioners (NPs), physician assistants (PAs), and certain other advanced practice providers (APPs) may order diagnostic tests, perform services within their scope of practice, and supervise diagnostic tests if permitted under state law.
CMS has made it clear that these practitioners may provide services and supervision consistent with their state’s scope of practice and Medicare regulations, which has expanded operational flexibility and allowed for more efficient use of physician resources.
Additionally, CMS clarified that diagnostic tests performed by PAs and NPs may be furnished in accordance with state scope of practice and Medicare requirements. However, PAs are not required to independently meet the supervision level assigned to the test, as the PA-physician relationship governs these services, while NPs must continue to comply with applicable supervision requirements unless otherwise specified.1
The Role of RRAs and RPAs
CMS continues to recognize the role of registered radiology assistants (RRAs) and radiology practitioner assistants (RPAs) in performing diagnostic imaging services under supervision. Diagnostic tests performed by RRAs or RPAs require direct supervision when permitted by state law.
Back in 2019, CMS did establish an important exception that allows RRAs and RPAs to perform certain diagnostic tests that are assigned a level of personal supervision under a direct supervision standard, provided this is permitted under state law and scope-of-practice regulations. In these scenarios, the supervising physician is not required to be physically present in the room but must meet the requirements for direct supervision. With CMS now recognizing real-time audio-video technology as an acceptable and ongoing method of meeting direct supervision requirements, this effectively allows these services to be performed with the supervising physician virtually present when clinically appropriate.
With this in mind, RRAs and RPAs may perform a variety of services, including components of procedures such as drainage procedures, biopsies, arthrograms, myelograms, and line placements. However, Medicare payment rules remain clear; it is not appropriate to separately bill for these services since they have a supervision status of “9” and the current RRA/RPA supervision exception does not apply to these types of procedures.
Billing in Non-Hospital Settings
Beyond supervision of non-physician practitioners, there is a separate but related billing concept that warrants attention in non-hospital settings. The concept of “incident to” billing remains unchanged and continues to apply only in non-hospital settings, such as physician offices or freestanding imaging centers and only for patient visits and not procedures, which are classified as significant services and therefore exempt from “incident to.”
Realistically, in imaging settings, virtually all services are classified as significant procedures under CMS guidelines, meaning “incident to” billing rarely if ever applies in those environments. For informational purposes, to bill services as “incident to,” the service must be part of a physician-established plan of care, the physician must have had a prior face-to-face encounter with the patient, and the physician must provide direct supervision, which may now be achieved virtually. Additionally, the service must be provided to an established patient for an established problem.
What This Means for Imaging Leaders
While supervision flexibility has increased, compliance expectations have not decreased. The expanded use of virtual supervision introduces additional operational considerations, including ensuring that real-time audio-video capability is available and functional, verifying physician availability at the time of service, maintaining documentation that supports supervision requirements, and aligning workflows with both federal and state regulations.
Additional Resources
1 https://www.cms.gov/files/document/r11901bp.pdf