The Proposed Rule on the Medicare Physician Fee Schedule (MPFS) for the 2026 fiscal year is out, and if adopted, it’s got very good news about direct supervision.
Hopefully, you know that for the last several years, it has been possible to provide direct supervision off-site as long as the supervising physician has the capability of communicating via audio-visual technology. In other words, if the doctor or other supervisor has a smartphone, they can provide direct supervision from afar. (Note that the capability need not be used; the supervisor doesn’t have to make any video calls, they must just have the capability of doing so.)
This is a very significant change from the old days, when the physician had to be in the office suite. I have spent far too much of my career trying to decide exactly what the “office suite” is. Does the physician need to be on the same floor? Available within 30 seconds? How about a minute? We never really knew.
Well, if the proposed fee schedule is finalized, we won’t need to, except in very limited circumstances. The Centers for Medicare & Medicaid Services (CMS) is proposing that for every service (with the exception of services that have a 10- or 90-day global surgery indicator), direct supervision can be provided off-site, permanently. Well, at least until the rule changes again.
First, it’s important to understand that this is only a proposal. As of right now, off-site supervision is kosher, but that will expire Dec. 31 unless the proposal is adopted. Whatever CMS chooses to do in the final fee schedule, which will come out sometime from late October through early December, will establish the expectations for Jan. 1 going forward.
I want to note that I still see articles that reference direct supervision requiring someone to be in the office suite. Since the start of the pandemic, back in early 2020, that has not been true.
In the proposal, CMS notes that cardiac, pulmonary, and intensive cardiac rehabilitation currently require direct supervision. CMS is asking whether people believe it is appropriate for those rehab services to be supervised by a remote physician. They’re also specifically seeking comment about the plan to permit off-site supervision of services with a zero-day global surgery window.
On the teaching physician front, however, the news is different. There, some of the supervision flexibility may be ending. CMS believes that it is important for teaching physicians to be physically present. Therefore, the proposal is that the ability to supervise residents remotely be permitted only outside of Metropolitan Statistical Areas (MSAs).
You can call it a “rural exception.”
Within a Metropolitan Statistical Area, if the proposal becomes rule, the physician will have to be physically present. You may be thinking, “how close will they need to be?” Honestly, from the preamble, I’m not entirely certain. And as a reminder, everything I am talking about is a proposal. We will cover the final rule as soon at it is out.
Programming note:
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I am not a proponent of measuring the impact of clinical documentation integrity (CDI) departments by case mix index (CMI) or complication/comorbidity capture rates (CCs/MCCs).
The Centers for Medicare & Medicaid Services (CMS) has released updated instructions for the Advance Beneficiary Notice of Noncoverage (ABN) Form CMS-R-131, extending the form’s
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