Oncology Rounds

What you need to know about Medicare’s physician supervision requirements

by Deirdre Saulet

CMS’s physician supervision requirements continue to be an area of uncertainty and confusion for many of our members. Here, we have compiled the most up-to-date information on physician supervision for chemotherapy and radiation therapy.

What is “supervision”?

CMS defines three levels of physician supervision for hospital outpatient departments:

  • General supervision: The physician or advanced practitioner (AP) must be available by telephone to provide assistance and direction if needed.
  • Direct supervision: The physician or AP providing supervision must be “immediately available” and “interruptible” to provide assistance and direction throughout the performance of the procedure; however, he or she does not need to be present in the room when the procedure is performed.
  • Personal supervision: The physician or AP must be in attendance in the room during the procedure.

Chemotherapy and radiation therapy require direct supervision

All therapeutic services are subject to CMS’s supervision requirements. Under these requirements, both chemotherapy and radiation therapy require direct supervision in both the hospital outpatient and freestanding settings.

Physicians and APs can provide supervision in hospital outpatient departments

CMS states that a physician or AP, such as a nurse practitioner (NP) or physician assistant (PA), must provide direct supervision of therapeutic services. The person providing supervision must be permitted to do so under state law, scope of practice regulations, and their hospital-granted privileges. In addition, he or she must have sufficient knowledge and training to be able "to furnish assistance and direction, not merely manage an emergency."

Does radiation therapy have special requirements?

CMS does not explicitly state that radiation therapy must be supervised by a radiation oncologist or trained AP, and although many providers have asked for clarification on radiation therapy requirements, CMS has declined to provide clarification. It states only that it requires that “the supervisory physician or non-physician practitioner must have, within his or her State scope of practice and hospital-granted privileges, the knowledge, skills, ability, and privileges to perform the services or procedure…The supervisory responsibility is more than the capacity to respond to an emergency…”

If your hospital-based cancer program is currently providing radiation therapy services without specialist supervision, your program leaders should consult with your institution's legal counsel to formulate a policy that they feel is clinically defensible.

More stringent requirements in the freestanding setting

CMS’s supervision requirements set a higher bar for physician offices and freestanding centers than for hospital outpatient departments. Whereas CMS allows APs to provide supervision in hospital outpatient departments, a physician is required to supervise these services in the freestanding setting. You can read more about the regulation differences. 

In addition, CMS does not require the supervising practitioner in the hospital outpatient setting to be physically present in the same office suite, just that he or she is "immediately available." In contrast, the supervising physician in the freestanding setting must be present in the office suite or center.

2016 MPFS clarification of “incident to” billing

In the 2016 MPFS final rule, CMS offered some critical clarifications around its supervision requirements. In the past, there’s been confusion about who should be billing for "incident to" services when the physician providing supervision is not the physician who ordered the service. As shown in the graphic below, CMS included new language that states that the supervising provider must also be the billing provider for "incident to" services.

Billing for 'incident to' services

HOP panel reduces supervision required for multiple cancer-related services

As mandated in the 2012 and 2013 Hospital Outpatient Prospective Payment System Final Rule, the Hospital Outpatient Payment Panel (HOP Panel) will evaluate the supervision requirements for each therapeutic outpatient code. In August, 2012, the HOP Panel made a number of recommendations to CMS to adjust physician supervision requirements for specific services, including many cancer-related services. This committee recommended that several services can safely be provided with general supervision, instead of direct supervision.

Although CMS declined to adopt all of the Panel’s recommendations, it did announce a reduction in the minimum required level of supervision for a number of services, including injection/infusion, intravenous, and central venous access services. Check out our 2013 HOPPS update: Key takeaways for cancer programs for more information.

What are your peers doing?

During our 2015 Infusion Center Benchmarking Survey, we asked our members how their institutions deal with physician supervision. As shown in the table below, the most common team member providing supervision for infusions is medical oncologists, and many institutions also use APs to provide supervision.

Who provides supervision for chemotherapy?

Supervision for chemotherapy

During our 2013 Oncology Medicare Reimbursement Update webconference, we discussed physician supervision requirements and asked our members how their institutions deal with physician supervision in their radiation therapy facilities. As shown in the table below, 80% of respondents use radiation oncologists, and far fewer (14%) use a combination of radiation oncologists and APs.

Who provides supervision for radiation therapy?

Supervision for radiation therapy

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