CMS Makes Permanent Major Changes to Medicare Physician Direct Supervision Rules Effective 2026
The Centers for Medicare & Medicaid Services (CMS) has finalized a significant and long-anticipated update to Medicare physician supervision requirements as part of the Calendar Year (CY) 2026 Medicare Physician Fee Schedule. Effective January 1, 2026, CMS will permanently allow physicians “direct supervision” through real-time, two-way audio and visual telecommunications, eliminating the long-standing requirement for a physician’s physical, on-site presence in many care settings.
Under the new rule, the presence of a supervising physician or other qualified practitioner is necessary during the entire performance of a service that must be directly supervised. However, they may do so remotely through interactive audio-video technology. Audio communication only is not up to standard. This policy marks a shift from historical Medicare regulations, where the overseeing practitioner has to be physically present in the office suite but not always in the same room as the patient.
Virtual direct supervision was first introduced by CMS in the COVID-19 public health emergency and then extended to December 31, 2025. In the eventual change, CMS mentioned better access to care among the patients, flexibility of schedules, and modernization of the care as the main reasons why the policy should become permanent.
The updated definition of direct supervision applies to many incident-to services under 42 CFR § 410.26, diagnostic tests under 42 CFR § 410.32, pulmonary rehabilitation services under 42 CFR § 410.47, and cardiac rehabilitation and intensive cardiac rehabilitation services under 42 CFR § 410.49. This flexibility has also been granted by CMS to Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs).
Nevertheless, CMS retained more excessive demands on surgical operations of a higher risk. The services with the global surgery indicators 010 (minor, 10-day global) and 090 (major, 90-day global) will still presuppose the physical, on-site presence of the physician so that patient safety can be ensured and prompt intervention can be provided.
The policy alteration will possess extensive operational and financial consequences. In the case of incident-to-services, physicians can now oversee the activities of the auxiliary personnel, like nurses or technicians, remotely but still charge using their own Medicare account number. This will enable the off-site ordering physicians to oversee and charge incident-to services, as long as they can access them through real-time audio-video communications, which could enhance the clinical supervision and the reimbursement process.
There is also an expectation of significant gains for Independent Diagnostic Testing Facilities (IDTFs). Several diagnostic imaging services, especially those that relate to contrast, would need direct physician supervision. Virtual capabilities to achieve this need could facilitate the staffing issue, better access to imaging services, and minimize operational inconveniences due to the limitation of the availability of physicians.
CMS stressed that the providers should go out of their way to ensure that they comply with the new rules. It is also recommended that healthcare organizations should revise the supervision protocols, provide adequate telecommunication platforms capable of facilitating real-time audio-visual interaction that is secure, and articulate the supervision arrangements to withstand any kind of audit. Also emphasized in CMS was the HIPAA compliance, as there is the exchange of protected health information on the virtual supervision.
Besides this, the providers are advised to seek the advice of the relevant accreditation agencies, such as the American College of Radiology and the American Society of Radiologic Technologists, to ensure that they are following the professional standards.
The move by CMS to permanently update direct supervision conditions is a significant change in Medicare policy, which marks a further transition to technology-based care delivery against the background of access, efficiency, and patient safety.
