‍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AB 460 updates this outdated framework by allowing: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.

‍On October 31, 2025, the Centers for Medicare & Medicaid Services (CMS) released the Calendar Year 2026 Medicare Physician Fee Schedule (PFS) Final Rule, establishing a landmark policy change for healthcare delivery.

Beginning January 1, 2026, supervising physicians and non-physician practitioners (NPPs) may permanently meet the “presence” and “immediate availability” requirements of direct supervision through real-time, two-way audio and video communication.

This update transitions a temporary COVID-era flexibility into a permanent feature of Medicare policy—reflecting CMS’s recognition that modern telecommunication tools can uphold safety, accessibility, and quality in clinical supervision.

Policy Overview

The 2026 Final Rule amends the federal definition of direct supervision to allow supervising clinicians to be virtually “present” using interactive audiovisual technology. This rule primarily applies to diagnostic tests governed by 42 CFR § 410.32, many of which previously required physical on-site supervision. Additionall,y the rule applies to incident-to services (§410.26), pulmonary rehab (§410.47), cardiac and intensive cardiac rehab (§410.49), as well as RHC and FQHC services requiring direct supervision (§405.2413).

Key Provisions

• Technology Standard: Direct supervision may now be satisfied through secure, real-time audio-video communication. Audio-only methods do not qualify.

• Applicable Settings: This flexibility applies to office-based practices and Independent Diagnostic Testing Facilities (IDTFs). Within IDTFs, only physicians with demonstrated proficiency in performing and interpreting the supervised test may provide remote oversight.

• Safety-Based Exclusions: Procedures with 010 (minor, 10-day global) or 090 (major, 90-day global) surgical indicators remain excluded. CMS emphasized the need for on-site physician availability for services with inherent procedural or postoperative risk.

This decision balances operational efficiency with patient safety, ensuring that virtual supervision enhances—but does not replace—appropriate in-person clinical presence.

Alignment with Future Outpatient Rules

CMS also indicated that similar provisions are expected within the forthcoming Hospital Outpatient Prospective Payment System (OPPS) Final Rule, which is pending Office of Management and Budget (OMB) review.

If finalized, these updates under 42 CFR §§ 410.27 and 410.28 would extend virtual supervision flexibility to hospital outpatient departments, harmonizing standards across outpatient and ambulatory care environments.

Implications for Healthcare Providers

The permanent adoption of virtual direct supervision carries significant implications for access, compliance, and workforce management.

1. Expanding Access to Care: Facilities in rural or underserved regions can now schedule diagnostic procedures without requiring a supervising physician to be physically on-site, reducing delays and improving patient throughput.
2. Enhancing Workforce Efficiency: Supervising physicians may oversee multiple locations remotely, optimizing specialist time, reducing non-clinical travel, and improving operational scalability.
3. Increasing Scheduling Flexibility: Centers can extend service hours—offering early, late, or weekend imaging—without compromising compliance, supervision, or patient safety.
4. Supporting Regulatory Consistency: This policy aligns Medicare supervision standards with state-level reforms such as California’s AB 460, which similarly authorizes real-time remote supervision for contrast-enhanced imaging beginning January 1, 2026.

Implementing CMS 2026 Virtual Supervision: A Compliance Framework

To ensure a seamless transition to virtual direct supervision under the new federal standard, Tether Supervision recommends the following best practices for imaging and diagnostic providers:

1. Technology Validation — Implement HIPAA-compliant audiovisual platforms that ensure:

• Real-time, uninterrupted two-way communication

• Latency monitoring and failover mechanisms

• Automated session logging for audit and verification

2. Policy and Protocol Revisions — Update institutional supervision manuals to clearly define:

• Virtual pre-test connectivity checks

• Supervisor engagement documentation standards

• Emergency escalation pathways (e.g., crash cart access and rapid response procedures)

3. State and Professional Alignment — Confirm that supervision practices remain consistent with:

• State-specific licensing and scope-of-practice laws

• ACR and ASRT guidance on contrast administration, injection safety, and technologist scope

• On-site clinical response requirements for moderate- or high-risk procedures

4. Documentation Rigor — Maintain contemporaneous records detailing:

• Supervising clinician credentials and participation times

• Any technical interruptions or corrective measures

• Patient consent and acknowledgment of virtual oversight

Tether’s documentation framework automates these records to ensure regulatory defensibility and operational transparency.

Quality Oversight and Future Expectations

CMS has indicated it will monitor outcomes related to virtual direct supervision through ongoing quality reporting, utilization reviews, and access metrics. Providers should proactively collect and analyze data on:

• Virtual vs. in-person supervision ratios

• Adverse event frequency and response times

• Patient and technologist satisfaction measures

These metrics will help both CMS and healthcare organizations evaluate the long-term efficacy and safety of tele-supervision frameworks.

Conclusion

The CY 2026 Medicare Physician Fee Schedule Final Rule represents a historic advancement in healthcare regulation, embedding virtual direct supervision into federal policy as a permanent, compliant, and scalable model of care.

For imaging centers, diagnostic testing facilities, and physician practices, this change unlocks new opportunities for access, flexibility, and modernization.

At Tether Supervision, we remain committed to helping organizations interpret these policy updates, design compliant operational protocols, and implement technology that meets both CMS and state-level supervision standards.

The future of clinical oversight is connected, compliant, and virtual—and it begins January 1, 2026.

Contact Tether Supervision to prepare your facility for the CMS 2026 implementation and optimize your supervision strategy for the year ahead.‍

‍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.‍