Empowering Radiation Oncologists: Tools, Insights and Resources 

To meet Medicare payment conditions, procedures in hospital outpatient departments and physician offices must comply with the Centers for Medicare and Medicaid Services (CMS) physician supervision requirements, which vary by service type and setting. Code level supervision details are available in the Medicare Physician Fee Schedule RVU file or through the CMS Fee Schedule lookup tool.

In the hospital outpatient setting, radiation therapy services require direct supervision by a physician or qualified non-physician practitioner, who must be immediately available to assist and direct the procedure. They are not required to be physically present in the room. The supervising provider must have the necessary hospital privileges and comply with state scope-of-practice laws.

Although CMS doesn’t mandate that a radiation oncologist supervise radiation therapy services, the ACR recommends a board-certified/board-eligible radiation oncologist for this role. This is supported by the CRCPD's training requirements and ACR Radiation Oncology Practice Accreditation standards, which emphasize the oncologist’s availability for direct care, quality review, and urgent treatment initiation 24/7.

CMS’s 2010 HOPPS final rule allows non-physician practitioners, such as physician assistants and nurse practitioners, to supervise therapeutic services within their scope of practice and hospital privileges, whether on or off campus. 

In the 2009 HOPPS final rule, CMS clarified that supervision requirements apply to Critical Access Hospitals (CAHs). In response to concerns from CAHs and small rural hospitals about meeting these requirements, CMS instructed Medicare Administrative Contractors (MACs) not to enforce physician supervision for outpatient therapeutic services at these facilities. This non-enforcement was extended through 2013 by legislative actions and has continued annually since.

In the CY 2018 HOPPS final rule, CMS reinstated non-enforcement of direct supervision for outpatient therapeutic services at CAHs and small rural hospitals with 100 or fewer beds for CY 2018-2019, allowing time for compliance and for submitting services to the Advisory Panel on Hospital Outpatient Payment for evaluation.

While non-enforcement continues for CAHs and rural hospitals, health systems in other settings have faced lawsuits under the False Claims Act, often related to failure to properly supervise radiation therapy, medical necessity issues, and billing violations. For examples of such litigation, visit the Department of Justice website.

Physician supervision of radiation therapy services in freestanding therapy centers requires direct supervision by a physician, excluding non-physician practitioners. CMS clarifies that while the physician need not be in the same room, they must be in the area and immediately available to assist and direct the procedure. The Social Security Act defines a physician as a doctor of medicine or osteopathy legally authorized to practice in the state.

Although CMS doesn’t require a radiation oncologist for supervision, the ACR recommends a board-certified/board-eligible radiation oncologist, supported by CRCPD training standards and NRC regulations. ACR Radiation Oncology Practice Accreditation also requires that a radiation oncologist be available for direct care, quality review, and urgent treatment initiation 24/7, or ensure appropriate coverage when unavailable.

With very few exceptions, diagnostic X-ray and other diagnostic tests payable under the physician fee schedule must be furnished under at least a general level of physician supervision and some require direct or personal supervision. 

Under the Social Security Act, Medicare covers services furnished "incident to" a physician’s professional service, typically rendered in physicians' offices and either provided without charge or included in the physician’s bills. Therapeutic services for hospital outpatients are among these covered "incident to" services, which must be performed under direct supervision by a physician.

To be covered, "incident to" services must meet these criteria:

1. Integral to the patient’s treatment course.
2. Commonly rendered without charge.
3. Typically provided in a physician’s office or clinic.
4. Delivered at the physician's expense.

Additionally, "incident to" services must be provided in non-institutional settings to non-institutional patients. Hospitals and off-campus provider-based facilities can only offer these services in distinct, identifiable parts of the facility. The CY 2016 Medicare Physician Fee Schedule (MPFS) final rule clarified who may bill for "incident to" services; see the ACR summary for details.