CMS Virtual Direct Supervision 2025: Key Questions for Radiology Practices

Will CMS’s Authority for Virtual Direct Supervision Extend Beyond 2025?

The CMS policy allowing virtual direct supervision of certain diagnostic tests via real-time audio and visual interactive telecommunications technology is currently set to expire on December 31, 2025, per the 2025 Medicare Physician Fee Schedule (MPFS) Final Rule. While this deadline may raise concerns, there is reason for optimism. The policy has been extended annually since its introduction in 2020, and strong advocacy from organizations like the the American College of Radiology (ACR) and Radiology Business Management Association (RBMA) support making it permanent, particularly for lower-risk services, due to its proven benefits in enhancing access without compromising safety.

What Does "Real-Time Audio and Visual Interactive Telecommunications Technology" Mean? What tools does that include?

This term refers to a setup where the supervising physician or practitioner can monitor and interact with the diagnostic procedure as it happens, using technology that provides both live video and live audio. Here’s a breakdown:

• Real-Time: The supervision occurs simultaneously with the test—no delays or recordings. The physician must be available to intervene immediately if needed.
• Audio and Visual: The technology must include both a live video feed (to see the patient, staff, or equipment) and two-way audio (to communicate instructions or address issues). CMS explicitly excludes audio-only methods (e.g., phone calls) for this purpose.
• Interactive: The system allows the supervisor to actively engage—asking questions, giving directions, or responding to the on-site staff (e.g., technologists) in real time.
• Examples: Think of platforms like Zoom for Healthcare, Doxy.me, or Microsoft Teams healthcare, or specialized telehealth software with embedded medical tools (e.g., patient reaction guides and contrast reaction algorithms), provided they meet CMS security and privacy standards (e.g., HIPAA compliance). The setup must ensure a stable, high-quality connection to support patient safety and effective oversight.

This approach leverages tools that became widespread during the pandemic, allowing flexibility in staffing and access to care, especially in rural or underserved areas where on-site radiologists might not be available.

Does Virtual Direct Supervision Require Active Monitoring of Every Procedure?

The CMS virtual supervision policy definitively establishes that “immediate availability” is achieved through real-time audio and visual interactive telecommunications technology, eliminating the need for physical presence through December 31, 2025. In practice, this does not require the remote supervising physician to actively monitor each procedure—such as watching every contrast injection via video., but it does mandate that the physician remain readily accessible through these tools to intervene if necessary, suggesting that the physician should be on and available throughout the procedure. In other words, being on the video call throughout is the historical equivalent to being in an office on-site. Historical guidance from Reed Smith's Thomas Greeson confirms this aligns with in-person supervision standards, where availability, not constant observation, is key. This remains the operational standard, as validated by consistent industry practice and CMS intent. Confirm that your virtual supervision tool meets these standards.

Does CMS Extend Authority for IDTFs to Directly Supervise Certain Diagnostic Tests via Real-Time Audio and Visual Interactive Telecommunications Technology?

Yes, the Centers for Medicare & Medicaid Services (CMS) has extended the authority for Independent Diagnostic Testing Facilities (IDTFs) to use real-time audio and visual interactive telecommunications technology for direct supervision of certain diagnostic tests. This extension to IDTFs stems from the 2024 Medicare Physician Fee Schedule (MPFS) Final Rule, released on November 1, 2023, and further clarified in updates like the 2025 MPFS Final Rule.

The updated PFS rule applies equally to both physician offices and ITDF settings, allowing the supervising physician—or, in physician offices, authorized practitioners like NPs or PAs under 42 CFR 410.32(b)(3)(ii)—to be virtually present rather than physically in the office suite. However, for IDTFs, only physicians proficient in the specific tests can supervise, as per the 'proficiency' requires of 42 CFR 310.33.

Which Diagnostic Tests Can be Supervised Remotely?

CMS ties the flexibility to services requiring "direct supervision" under Medicare rules (42 C.F.R. §§ 410.32(b)(3)(ii)). Here’s what we know:

• General Scope: This applies to diagnostic tests that historically required a supervising physician’s immediate availability. These include imaging studies and other procedures where a physician oversees the administration or performance but doesn’t necessarily need to be physically present.
• Temporary Subset: Virtual direct supervision is in place through the end of the year for Level 2 radiology tests, although on-going efforts for permanence are taking place. Tests like MRI and CT scans with contrast media (often classified as "Level 2" tests) are commonly cited, as they require direct supervision due to the use of contrast agents. Other examples might include certain ultrasound procedures or stress tests, depending on the IDTF’s enrollment and the codes listed on their CMS-855B application (Attachment 2). CMS has indicated that virtual supervision applies to services where real-time oversight ensures safety and quality, but not to "Level 3" tests (e.g., fluoroscopic-guided procedures like barium swallow studies) that require in-room presence.
• Permanent Subset: CMS is permanently allowing virtual supervision for the following services:
  • Services furnished incident to a physician’s service when they are provided by auxiliary personnel employed by the physician and working under the physician’s direct supervision and for which the underlying HCPCS code has been assigned a PC/TC indicator of “5.” There typically refer to 'incident to' services.
  • Services described by CPT code 99211: office and other outpatient visits for the evaluation and management of an established patient that may not require the presence of a physician or other qualified healthcare professional. This is typically for established patients engageing in low-complexity visits.

Since IDTFs must specify the diagnostic tests they perform (via CPT codes) on their Medicare enrollment application, the eligible tests depend on what each facility is approved to provide. For a precise list, you’d need to check with the IDTF in question or CMS directly, as public sources don’t provide a universal catalog.

How Have Organizations Successfully Implemented Remote Contrast Supervision Policies?

Organizations have successfully implemented remote contrast supervision policies by adopting proven strategies that ensure compliance and efficiency. These include deploying robust telecommunications infrastructure (e.g., secure, high-quality audio/video platforms), establishing comprehensive training programs for staff and supervisors, and aligning with CMS, state, and accreditation requirements. Radiology practices and hospitals have leveraged these elements to seamlessly transition to virtual oversight, particularly at off-campus sites, demonstrating that a structured approach—supported by legal counsel—guarantees operational success and patient safety. Contact Tether Supervision to learn more.

Additional Notes

Temporary Extension: The current extension through December 31, 2025, applies broadly to diagnostic tests requiring direct supervision in IDTFs and physician offices. After that, unless CMS makes it permanent, in-person supervision might be required again unless further extended.

Why It Matters: This policy reduces the need for on-site physicians, potentially lowering costs and improving access, but it’s under scrutiny for long-term safety and efficacy. Advocacy from groups like the Radiology Business Management Association (RBMA) pushes for permanence, citing no significant overuse or safety issues to date.

Uncertainty: CMS’s incremental approach—testing permanence with "lower risk" services—leaves some ambiguity. The diagnostic imaging community is likely to push for clarity in upcoming comment periods.

If you need specifics for a particular IDTF or test, reaching out to CMS or checking the facility’s Medicare enrollment details would be the next step, as the exact tests depend on their approved scope of practice.