With two coordinated rules, the 2026 Medicare Physician Fee Schedule (PFS) Final Rule, issued October 31, 2025, and the 2026 Hospital Outpatient Prospective Payment System (OPPS) Final Rule, issued November 21, 2025, CMS has permanently authorized the use of real-time, two-way audio-video technology to meet “direct supervision” requirements for many diagnostic tests, including advanced imaging with contrast, across both office-based and hospital outpatient settings. These policies take effect January 1, 2026.

For imaging leaders, radiology groups, and hospital administrators, this is a structural change, one that reshapes how contrast-enhanced CT and MRI can be supervised, staffed, and scaled. For Tether Supervision, it further validates the model we were built for: safe, compliant virtual supervision paired with on-site support.

What CMS Means by Virtual Direct Supervision

Under both the PFS and OPPS rules, CMS maintains the classical definition of direct supervision: the supervising clinician must be immediately available to assist throughout the performance of the diagnostic test. What has changed is how that presence can be fulfilled. Beginning in 2026, immediate availability may be achieved via real-time, two-way, interactive audio and video. The connection must remain active and capable of supporting live intervention for the entire duration of the test. Audio-only communication does not satisfy the standard, and services associated with 010- and 090-day global surgical periods remain excluded due to safety and postoperative considerations.

This distinction is particularly relevant to advanced diagnostic imaging, where Level 2 tests such as CT with contrast and MRI with contrast have always required direct supervision. CMS’s updated rules mean that these contrast-enhanced studies can now be supervised virtually, provided the supervising radiologist or NPP maintains continuous, real-time audio-video availability and can interrupt other activities when needed.

The Role of State Law and Scope-of-Practice Requirements

Although the Medicare rules establish a federal baseline, CMS repeats in both the PFS and OPPS regulations that virtual direct supervision is permissible only where state law allows—or does not explicitly prohibit—remote supervision. Many states are modernizing radiologic technologist scope-of-practice statutes to align with contemporary imaging workflows, but others maintain legacy supervision frameworks or remain ambiguous regarding virtual supervision in contrast studies. Imaging centers, radiology groups, and health systems therefore must reconcile three layers of policy: CMS reimbursement rules, state practice acts and board guidance, and internal medical staff bylaws and privileging standards.

Because contrast administration often triggers specific state-level requirements around competency, escalation, and adverse reaction management, a careful review of state rules remains necessary even after CMS’s 2026 changes. A compliant virtual supervision program is one that satisfies Medicare’s technology requirements and state-based supervision constraints simultaneously.

Operational and Clinical Implications for Imaging Centers

For imaging leaders, these changes have immediate implications for staffing, coverage models, and workflow design. Virtual direct supervision allows a supervising radiologist to remain “immediately available” without being physically located in the imaging suite, enabling new models of multi-site coverage—particularly valuable in rural and underserved regions where securing on-site supervision has historically been challenging. Hospitals and health systems may now design hybrid models that combine qualified on-site technologists or nurses with a remotely available supervising physician, increasing the reliability of coverage while reducing staffing inefficiencies.

This shift places greater emphasis on training for on-site personnel, who must recognize and escalate adverse reactions, execute protocol adjustments under supervision, and operate within state scope-of-practice boundaries. It also requires imaging organizations to evaluate their technology infrastructure. Real-time audio-video capability must be HIPAA-compliant, stable, and documented. Audit trails—who supervised, when, and under which circumstances—become central to both compliance and risk management. Quality assurance programs will increasingly track response times, contrast reaction management, and adherence to virtual supervision protocols as part of continuous oversight.

Why This Matters for Contrast-Enhanced CT and MRI

Advanced imaging with contrast often represents the most operationally complex portion of outpatient radiology. These Level 2 diagnostic tests require oversight from a radiologist or qualified NPP who is immediately available to intervene should patient status change. By making virtual direct supervision permanent, CMS is aligning supervision standards with the realities of modern imaging: distributed networks, uneven geographic supply of radiologists, and rising demand for high-acuity diagnostic studies.

Virtual direct supervision offers imaging centers the ability to stabilize coverage, improve scheduling flexibility, reduce delays, and ensure that Medicare beneficiaries receive timely access to imaging—even when in-person supervision is not feasible. As a result, patients benefit from shorter wait times and more consistent quality of care across locations.

How Tether Supervision Supports Compliance and High Reliability

Tether Supervision was built for the workflows CMS has now formally recognized. Our platform—and the broader Tether model—supports real-time, HIPAA-compliant audio-video supervision that satisfies Medicare’s direct supervision requirements while integrating seamlessly with on-site technologists. We help clients align federal regulations with state laws, update internal supervision policies, and train teams to confidently operate under virtual supervision conditions. Because our model includes both virtual and on-site coverage when required, imaging centers can adapt to state variations and mixed-site footprints without the fragmentation seen in single-mode vendors.

Beyond compliance, Tether provides structured escalation pathways, incident reporting tools, and QA frameworks designed specifically for contrast-enhanced imaging. These systems allow organizations to demonstrate reliability and readiness—key considerations for hospital leadership, accreditation bodies, and regulatory reviewers.

Key Dates and What’s Next

The two foundational dates for imaging organizations planning 2026 operations are:

• October 31, 2025 – CMS finalizes the PFS rule making virtual direct supervision permanent for Level 2 diagnostic tests in physician offices and IDTFs.
  
  

• November 21, 2025 – CMS finalizes the OPPS rule extending the same virtual supervision standards to hospital outpatient departments, including off-campus provider-based departments.
  
  

• January 1, 2026 – Both rules take effect, formally integrating virtual direct supervision into Medicare’s standard supervision framework.

Together, these changes mark a decisive shift toward modernized supervision in diagnostic imaging. For health systems preparing for 2026, the focus now turns to updating policies, aligning state law interpretations, credentialing supervising clinicians accordingly, configuring compliant A/V technology, and preparing on-site teams to operate confidently within virtual supervision workflows.

Tether Supervision will continue supporting organizations as they adopt these new standards, ensuring that patient safety, regulatory compliance, and operational efficiency remain at the forefront in this next era of contrast imaging supervision.

‍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.‍