Effective January 1, 2026, the Centers for Medicare & Medicaid Services (“CMS”) have formally adopted permanent revisions to the definition of direct supervision under Medicare. These updates were finalized in the Calendar Year (“CY”) 2026 Medicare Physician Fee Schedule (“MPFS”) Final Rule and extend temporary flexibilities that were originally implemented during the COVID-19 Public Health Emergency (“PHE”).1 The revisions reflect CMS ongoing efforts to modernize supervision standards, expand access to healthcare services, and respond to workforce constraints, while continuing to prioritize patient safety.
Prior to the PHE, Medicare generally required that, for Medicare Part B services that mandate direct supervision, the supervising physician or qualified practitioner be physically present within the office suite or facility, though not necessarily in the same room, and immediately available to furnish assistance and direction throughout the performance of the service. Remote or virtual availability did not satisfy the direct supervision requirement.
Under the CY 2026 Final Rule, CMS has now permanently expanded the definition of direct supervision to allow for virtual presence in specific circumstances. Under the revised standard, direct supervision may be satisfied when the supervising physician or practitioner is immediately available to furnish assistance and direction and is accessible through real-time, two-way interactive audio and visual telecommunications technology, in lieu of physical on-site presence. CMS has expressly clarified that audio-only communication does not meet the direct supervision standard, and that the supervising practitioner must be able to both see and hear the service as it is being furnished in real time and must be positioned to intervene without delay, if necessary.
The updated definition applies to Medicare Part B services that require direct supervision, as defined and regulated by CMS, including, but not limited to, “incident to” services furnished by auxiliary personnel under 42 C.F.R. § 410.26, diagnostic tests requiring direct supervision under 42 C.F.R. § 410.32, pulmonary rehabilitation services under 42 C.F.R. § 410.47, and cardiac rehabilitation and intensive cardiac rehabilitation services under 42 C.F.R. § 410.49. However, higher-risk surgical procedures assigned global surgery indicators 010 or 090, which are major procedures subject to a 90-day global period, continue to require the supervising physician’s physical presence on site to safeguard patient safety and allow for immediate in-person intervention. CMS has also extended the availability of virtual direct supervision, using real-time audio-visual technology and not audio-only communication, to Rural Health Clinics and Federally Qualified Health Centers, to the extent that such services are subject to direct supervision requirements under applicable Medicare Part B regulations.
CMS indicated that this flexibility is intended to facilitate care delivery in physician offices, outpatient environments, and other non-facility settings. Accordingly, virtual direct supervision may not be used to satisfy Medicare supervision requirements applicable to many surgical procedures furnished under global surgical packages.
By making this expanded definition of direct supervision permanent and inclusive of real-time audio-visual telecommunications, CMS has provided Medicare providers with lasting regulatory clarity and enhanced operational flexibility. These modifications are expected to improve access to care, accommodate modern care delivery models, and reduce administrative burdens, while maintaining patient safety through immediate supervisory availability.
If you would like a more detailed analysis of how these updates may affect specific service lines, billing processes, or compliance initiatives within your organization, please do not hesitate to contact us. The Maceira Zayas healthcare and health policy team is available to assist.
1 Medicare and Medicaid Programs; CY 2026 Payment Policies Under the Physician Fee Schedule and Other Changes to Part B Payment and Coverage Policies; Medicare Shared Savings Program Requirements; and Medicare Prescription Drug Inflation Rebate Program, CMS-1832-F, 90 FR 49266-50481 (Nov. 5, 2025).
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