‍October 7, 2025, marks a milestone for California radiology.

Governor Gavin Newsom has officially signed Assembly Bill 460 (AB 460) into law, modernizing the state’s definition of “direct supervision” for contrast-enhanced imaging procedures.

Beginning January 1, 2026, radiologists in California will be able to meet supervision requirements either in person or remotely via real-time audio and video, with full access to imaging records and the ability to direct licensed onsite personnel.

This marks the first time California has formally recognized virtual supervision as an equivalent, compliant form of direct oversight for contrast-enhanced CT and similar procedures — aligning state policy with existing Centers for Medicare & Medicaid Services (CMS) rules that have been in place since 2020.

What AB 460 Changes

For decades, California required supervising physicians to be physically present within the facility whenever contrast was administered by a technologist — a rule that limited flexibility and often constrained access to care, particularly in rural or multi-site imaging settings.

AB 460 updates this outdated framework by allowing:

• Virtual direct supervision: Radiologists may now provide real-time oversight via secure audio/video communication (excluding audio-only).

• Immediate availability: The supervising physician must remain available to intervene or direct onsite personnel if needed.

• Access to imaging records: Physicians must have immediate access to the relevant imaging information to inform their supervision.

Key compliance detail: When supervision is provided remotely, facilities must have:

• Written safety protocols for contrast administration and emergencies, and

• Onsite licensed personnel — a physician, registered nurse (RN), nurse practitioner (NP), clinical nurse specialist (CNS), or physician assistant (PA) — available to respond at the physician’s direction.

This onsite requirement must be reflected in both protocol documentation and staffing models for compliance.

Why AB 460 Matters for Imaging Centers

AB 460 represents a transformative update for outpatient imaging and radiology operations.

1. Expands Access to Care: For rural and community-based imaging centers, the ability to leverage virtual supervision ensures patients can access contrast-enhanced exams without delays or rescheduling due to radiologist availability.

2. Strengthens Patient Safety: By requiring trained onsite clinicians and standardized emergency protocols, the new law maintains — and in many cases, enhances — safety standards while enabling modern, technology-driven workflows.

3. Aligns with CMS Policy: CMS has recognized virtual direct supervision for diagnostic testing and incident-to services since 2020. AB 460 finally brings California’s Health & Safety Code into alignment with these federal standards, eliminating the compliance tension between state and federal definitions.

4. Reduces Operational Bottlenecks: Facilities can now scale coverage across multiple sites more efficiently, improving scheduling flexibility and optimizing radiologist workloads — without sacrificing oversight or compliance.

Tether Supervision’s Role in the Legislative Process

Tether Supervision closely tracked and contributed to AB 460 from its early drafts through final passage.

Our policy and operations team submitted written feedback and recommendations that helped refine the bill’s language — including clarifying the scope of virtual supervision and the requirements for onsite clinical responders.

We also worked alongside imaging leaders and advocacy groups to ensure the legislation supports:

• Equitable access for small, rural, and independent imaging centers

• Clarity for radiologists and administrators designing compliant workflows

• Consistency with federal CMS and ACR standards

AB 460’s final language reflects a balance between safety, access, and operational practicality — the same balance that underpins Tether’s supervision model.

Preparing for Implementation: What Centers Should Do Now

With the law set to take effect on January 1, 2026, imaging centers should begin preparing their infrastructure, documentation, and staff training now.

Tether recommends:

• Reviewing current supervision protocols to identify areas that require revision for compliance under AB 460.

• Updating written procedures to incorporate virtual oversight workflows, including contrast reaction escalation and documentation standards.

• Verifying onsite coverage — ensure licensed personnel are consistently available to respond during remote supervision.

• Implementing HIPAA-compliant AV technology capable of supporting real-time communication and record access.

• Training technologists and onsite staff on the new expectations for communication and escalation under virtual oversight.

Tether provides direct guidance and implementation support to imaging centers navigating this process, ensuring a smooth transition that’s fully compliant by 2026.

A Win for Radiology — and for Patients

AB 460 is more than a policy win. It’s a signal that California is ready to modernize supervision and embrace the proven safety and efficiency of virtual radiology oversight.

• For imaging centers, it means fewer delays, more flexibility, and broader patient access.

• For radiologists, it means a sustainable, scalable model for coverage.

• For patients, it means timely, high-quality care delivered where and when it’s needed most.

At Tether Supervision, we’re proud to have supported this effort and remain committed to helping imaging centers translate legislation into safe, compliant, real-world practice.

We’re here to help your center prepare for implementation in 2026 — and lead confidently through the transition.

‍The Centers for Medicare & Medicaid Services (CMS) has released its CY 2026 Medicare Physician Fee Schedule (PFS) Proposed Rule, and with it comes a major shift in how supervision and telehealth services are regulated and reimbursed.

The proposal introduces long-awaited clarity around virtual direct supervision, builds on CMS’s evolving telehealth policies, and signals a permanent departure from some of the pandemic-era limitations. These changes could significantly impact radiology, diagnostic testing, outpatient imaging, and incident-to services across the country, especially in rural and underserved areas.

In this article, we’ll break down the proposed changes, what they mean for physician practices, and how healthcare organizations can prepare.

1. CMS Proposes Permanent Virtual Direct Supervision for Key Services

CMS is proposing to permanently adopt a definition of "direct supervision" that allows for real-time audio/visual telecommunications (excluding audio-only) for certain services. This rule would apply across:

• Incident-to services under § 410.26

• Diagnostic tests under § 410.32

• Pulmonary rehabilitation under § 410.47

• Cardiac and intensive cardiac rehabilitation under § 410.49

This change would codify the flexibility introduced during the COVID-19 Public Health Emergency and could transform how supervising physicians manage multi-site service delivery, especially for services involving contrast-enhanced imaging, diagnostic testing, and clinical staff workflows.

Excluded for Now: Services with a global surgical indicator of 010 or 090 would not be eligible for virtual direct supervision. CMS is also seeking feedback on whether 000 global indicator procedures should be excluded due to patient safety concerns.

2. Streamlined Telehealth Services Review Process

CMS is also proposing to simplify the process for adding services to the Medicare Telehealth Services List by:

• Removing the distinction between provisional and permanent services

• Focusing reviews solely on whether the service can be safely delivered using interactive two-way audio-video telecommunications

This could accelerate access to telehealth-reimbursable services and make it easier for emerging clinical services, including those in imaging, oncology, or chronic care management, to be adopted under Medicare.

3. Removal of Frequency Limitations for Inpatient and Critical Care Telehealth

In another move that aligns with long-standing provider feedback, CMS is proposing to permanently remove telehealth frequency limitations for:

• Subsequent inpatient visits

• Subsequent nursing facility visits

• Critical care consultations

This would give physicians and supervising practitioners more discretion to determine the appropriate cadence of virtual check-ins based on patient needs, not outdated frequency caps.

4. Implications for Radiology and Outpatient Imaging

For radiology groups, outpatient imaging centers, and hospital-based practices, these changes carry important implications:

• Virtual contrast supervision workflows, which rely on direct supervision for technologists administering contrast, could be permanently validated at the federal level under § 410.32

• Incident-to protocols that require on-site supervision (e.g., nurse-administered injections, diagnostic studies) could now permanently be supported via HIPAA-compliant video

• Scheduling flexibility would improve, as supervising physicians could permanently oversee services remotely without delaying care due to location constraints

If finalized, these rules would also provide a permanent regulatory foundation for platforms like Tether Supervision, which enable secure, compliant virtual oversight across multiple care sites.

5. Key Takeaways and Next Steps

Healthcare organizations should begin preparing for virtual supervision now if they haven't yet:

• Audit your supervision policies to identify services that could transition to virtual oversight

• Train staff on what virtual direct supervision entails, and ensure AV systems meet CMS requirements

• Identify your needs and consider whether choosing a virtual supervision provider is right for your organization

• Comment on the rule: CMS is actively soliciting feedback, particularly around services with a 000 global indicator. This is an opportunity to shape federal policy to reflect operational realities

Conclusion

The CY 2026 Medicare Physician Fee Schedule Proposed Rule marks a major milestone in the evolution of virtual supervision and telehealth policy. By aligning supervision rules with technology-driven workflows and expanding telehealth access, CMS is moving toward a model that reflects the realities of modern care delivery.

Whether you’re a radiology group, an outpatient imaging center, or a hospital network managing contrast-enhanced exams and incident-to services, these proposals offer new flexibility -- and a chance to rethink how your team delivers safe, scalable, and compliant care.

You can read the full 2026 Medicare Physician Fee Schedule (PFS) Proposed Rule summary here.‍

‍On April 1, 2025, California took a significant step toward improving access to diagnostic care with the passage of Assembly Bill 460 (AB 460) through committee action. The bill, which garnered unanimous support with a 15-0 vote in the Committee on Appropriations, redefines supervision requirements for radiologic technologists administering contrast materials, aligning California law with federal standards and addressing long-standing barriers to timely patient care.

Background and Need for AB 460

Under existing California law, specifically the Radiologic Technology Act (California Health and Safety Code, Section 106985), radiologic technologists are required to perform venipuncture for contrast administration under the direct, on-site supervision of a licensed physician or surgeon. This meant the supervising physician had to be physically present and available within the facility to intervene if needed. While intended to ensure patient safety, this requirement created significant delays in care, particularly in rural and community hospitals where on-site radiologists are often unavailable.

Assemblymember Phillip Chen, the bill’s author, highlighted these challenges during the committee hearing: “Current law requires on-site supervision for radiologic technologists who are administering contrast materials, which has created significant delays and barriers in access to care.” These delays have been particularly acute in urgent or emergency cases, where the absence of an on-site radiologist could postpone critical imaging procedures.

Ryan Spencer, representing the California Radiological Society (CRS), the bill’s sponsor, emphasized the practical implications: “In many rural and community hospitals, having an on-site radiologist at all times simply isn’t possible. This results in patients experiencing delays in care… not because of lack of equipment or trained technologists, but because of an outdated supervision rule.”

What AB 460 Changes

AB 460 amends the Radiologic Technology Act to redefine “direct supervision” for radiologic technologists performing venipuncture. The new definition allows a licensed physician to supervise remotely via real-time audio and video communication, provided they have immediate access to the patient’s electronic medical records and the ability to intervene through standing orders or protocols. This aligns California with the federal Centers for Medicare & Medicaid Services (CMS) policy, which has permitted virtual direct supervision since 2020 and is extended through 2025.

The bill also includes a critical safety provision, added through recent amendments, requiring facilities to have qualified personnel physically present on-site during contrast administration. These personnel must be capable of responding immediately to any adverse reactions, ensuring patient safety is not compromised by the radiologist’s remote presence.

Spencer underscored this balance: “AB 460 maintains and strengthens patient safety… there will be somebody on-site physically to be able to respond to the adverse reaction.”

Addressing Committee Concerns

During the committee hearing, legislators raised important questions about the implementation of remote supervision. Assemblymember Pilar Schiavo sought clarification on how remote supervision would work in practice: “Can the person who is remote… see what’s happening, or are they on the phone? How can they monitor or engage with what’s happening on the ground remotely?”

Chen and Spencer explained that the bill mandates both audio and video components, ensuring the radiologist can visually monitor the procedure and communicate in real-time. Spencer noted, “The reason why a radiologist needs to be on-site is to answer any questions… They can just access them through video teleconference… and be able to answer those questions.” This allows radiologists to provide guidance on contrast type, precautions, or procedural adjustments without being physically present.

Schiavo also inquired about geographic limitations for the supervising radiologist, to which Spencer clarified, “They would still be a licensed physician in the State of California… but there’s nothing in the bill that says the person has to be a certain radius from the clinic.” This ensures that only California-licensed physicians can supervise, maintaining regulatory oversight while offering flexibility in location.

Assemblymember Darshana Patel raised concerns about data security, asking, “When it’s done via telehealth, is there a requirement or any sort of assurance that these will be secure lines… as it is health data?” Spencer confirmed that while the bill does not specify security protocols, telehealth networks used for such purposes must adhere to established standards for data privacy and security, ensuring secure communication channels beyond casual tools like FaceTime.

Alignment with Federal and State Practices

AB 460 brings California in line with federal CMS policy, which has allowed virtual direct supervision since 2020, a policy proven “safe and effective” through 2025. More than a dozen states, including Texas, Florida, New Jersey, and Alabama, have already adopted similar approaches, recognizing that radiologists can effectively supervise remotely while trained technologists perform procedures under strict protocols.

Impact and Support

The bill is expected to reduce unnecessary delays, relieve strain on the radiology workforce, and improve access to care, particularly in underserved areas. Chen cited examples of telemedicine bridging gaps from Catalina Island to Palmdale, illustrating its potential to connect patients with specialists across distances.

The California Radiological Society and the California Medical Association, represented by George Soares, voiced strong support. Soares affirmed, “George Soares with the California Medical Association in support,” reflecting broad medical community backing. No opposition was recorded during the hearing, and the bill passed with a unanimous 15-0 vote, with legislators like Heath Flora, Maggie Krell, and Joaquin Arambula voting in favor.

Financial and Statutory Notes

The bill addresses financial implications by noting that the California Constitution requires the state to reimburse local agencies and school districts for certain mandated costs. However, AB 460 specifies that “no reimbursement is required by this act for a specified reason,” likely due to its alignment with federal standards already in practice.

Looking Ahead

Having passed the Committee on Appropriations on April 1, 2025, AB 460 now moves to the broader legislative process. Its focus on modernizing supervision without compromising safety positions it as a practical solution to California’s healthcare access challenges, particularly for rural patients. As Assemblymember Patel, a mother of athletes familiar with radiology needs, noted, “I can see the need for this.” With strong legislative support and clear patient benefits, AB 460 is poised to enhance the efficiency and equity of radiologic care across the state.

Update: AB 460 was read in the CA Senate Committee on Health on July 2nd, 2025. Read our full analysis here.