The Centers for Medicare & Medicaid Services (CMS) has just issued a proposed rule that announces and solicits public comments on proposed policy changes for payments under the Medicare Physician Fee Schedule (MPFS) effective on or after January 1, 2026. CMS proposes to make permanent the authority for physician offices and independent diagnostic testing facilities (IDTFs) to directly supervise certain diagnostic tests via real-time audio and visual interactive telecommunications technology. Currently virtual direct supervision of Level 2 radiology tests — MRI and CT with contrast media — is in place only until the end of this year, December 31, 2025.

CMS has proposed to amend 42 CFR 410.32(b)(3)(ii) to read with no sunset date: “Direct supervision in the office setting means that the physician (or other supervising practitioner) must be present in the office suite and immediately available to furnish assistance and direction throughout the performance of the service. It does not mean that the physician (or other supervising practitioner) must be present in the room when the service is performed. The presence of the physician (or other practitioner) required for direct supervision may include virtual presence through audio/video real-time communications technology (excluding audio only)…”

The excitement in the radiology community for this proposal is tempered by recent statements made by the Drugs and Contrast Media Committee of the American College of Radiology (ACR) as well as the American Society of Radiologic Technologists (ASRT) at its the Annual Governance and House of Delegates Meeting. 

ACR Drugs and Contrast Committee

The statement from the ACR Drugs and Contrast Committee updates the committee's last statement on virtual supervision on February 26, 2024. Last year's statement recommended that during the virtually supervised study there be on-site either a radiologist or other physician (including radiology residents and fellows) OR “another qualified person," the latter acting under the general supervision of a physician. At that time the ACR did not restrict who performed the direct supervision of the contrast study, nor did it specify who on-site qualified persons could be, so long as they met certain training and capability criteria. 

This year's ACR committee statement allows for on-site direct supervision of contrast studies by an on-site radiologist, other physician, or qualified licensed practitioner. But, according to the statement, virtual direct supervision of “qualified on-site personnel” during contrast studies should only be performed by a physician, despite Medicare rules that permit certain non-physician practitioners who are permitted by state law and their state scope of practice to supervise contrast studies, whether physically present on site or virtually present. Further, the new ACR committee statement provides that the on-site personnel, in addition to the radiologic  technologist, must include at least one licensed practitioner. Unfortunately, the ACR statement does not define what it means by “licensed practitioner” even though this undefined individual must be on site during virtually supervised contrast studies if a radiologist or other physician is not available to be on site. The statement only provides a short list of licensed practitioners who “per CMS” are “relevant in radiology” — that includes nurse practitioners, physician assistants and clinical nurse specialists. The irony is that since this list comprises the only “qualified licensed practitioners” who can satisfy the on-site supervision requirement,  it seems to belie the reason to offer on virtual supervision in the first place. 

ASRT Practice Standards for Medical Imaging and Radiation Therapy

At the 2025 Annual Governance meeting, the ASRT House of Delegates approved the following amendment to Standard 4, General Criteria of the ASRT Practice Standards for Medical Imaging and Radiation Therapy: 

“Administers contrast and other medications only when a licensed practitioner is physically present  [in lieu of the words ‘immediately available’] to ensure proper diagnosis and treatment of adverse events." It is hard to understate the devasting blow of this ASRT practice standard amendment to those physician offices and IDTFs who are using virtual supervision to meet Medicare direct supervision requirements for Level 2 tests with contrast.

The glossary of the ASRT Practice Standards define a licensed practitioner as a “medical or osteopathic physician, chiropractor, podiatrist or dentist who has education and specialist training in the medical or dental use of radiation and is deemed competent to perform independently or supervise medical imaging or radiation therapy procedures by the respective state licensure board.”

Unfortunately, some state agencies that regulate imaging services performed on an outpatient basis in their states cite practice standards of the American Society of Radiologic Technologists in their on-site inspection reports. I fear the consequences of ASRT's recent standards changes. Clearly, some radiologic technologists look with disfavor on the virtual supervision of their work by physicians or limited licensed physicians. But in making this standards change, ASRT may actually threaten the financial viability of many of the imaging centers where they work in states where those standards are part of the regulatory framework. 

One has to hope that the diagnostic radiology community will unite in supporting CMS's adoption of their new proposed permanent virtual supervision rule. And one hopes that ACR and ASRT will be persuaded rethink their recent statements.