Supervision Rules in Radiology

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Diagnostic tests paid under the Medicare Physician Fee Schedule (MPFS) for the physician office and the Outpatient Prospective Payment System (OPPS) for hospital outpatient departments are regulated by the Centers for Medicare & Medicaid Services (CMS) by way of its supervision rules.  A supervising physician provides oversight of the medical (technical) components of the facility.  Duties include overseeing quality assurance, testing of equipment, development of protocols for the studies, creating policies and procedures that guide the medical operations of the organization, as well as the oversight of the healthcare staff.  The objective is to ensure study quality and patient safety.

Three Types of Supervision

General supervision means that the imaging is done under the control and direction of the supervising physician; it requires that the supervising physician verify that the technology is working properly and that protocols are developed and followed by the staff.  However, the physician is not required to be present during the performance of the exam.


Direct supervision requires the supervising physician to be in the facility and immediately available.  However, the physician is not required to be in the room.  For example, the supervising physician must be at the facility when a qualified technologist is administering a contrasted study.


Personal supervision requires that the supervising physician be in the room where the study is being performed.

Physician Supervision Indicators

For coding and billing, supervision requirements are indicated by physician supervision indicators that Medicare assigns to each CPT code.

The most common indicators are:

0 – Procedure is not a diagnostic test or procedure is a diagnostic test, which is not subject to the physician supervision policy

1 – Procedure must be performed under general supervision of a physician

2 – Procedure must be performed under the direction supervision of a physician

3 – Procedure must be performed under the personal supervision of a physician

9 – Concept does not apply

In order to properly bill for the study, you must make sure that the study that was performed had the appropriate supervision level that Medicare requires.  If for example, Medicare is billed for exams that have been designated as needing direct supervision, but the supervising physician was not at the facility, it may consider it as fraudulent and in violation of the False Claims Act, which could result in revocation from its program, having to give back payments, receiving penalties, and imprisonment.

In response to comments that the current requirement of personal supervision of some diagnostic studies is too restrictive and that the reduction of the level of supervision would improve efficiency of care, Medicare has revised its supervision rules.  Effective 1/1/19, diagnostic tests paid via the MPFS, as well as Medicare hospital outpatients, that are performed by registered radiologist assistant (RA), who has been certified and is registered with the American Registry of Radiologic Technologists, or a radiology practitioner assistant (RPA) who is certified by Certification Board of Radiology Practitioner Assistants, which had previously been required to have the personal level of supervision has now been modified to a lesser level of direct physician supervision, as permitted by state law and its scope of practice regulations.  This relaxed standard only applies to supervision requirements; it does not modify existing restrictions on the current scope of services of RAs or RPAs.  Therefore, RAs and RPAs may perform diagnostic tests without the supervising physician being in the same room if permitted within the scope of their state licensure.  Furthermore, only physicians may supervise other technologists who perform diagnostic tests.

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