Direct Supervision Goes Virtual in 2026

See how this impacts Incident-To

The Final Rule introduces an unexpected but significant shift, specifically in how direct supervision for incident-to services may now be met. On its surface, the change appears straightforward, yet it brings practical considerations that every physician and mid-level provider as well as practice leader should weigh carefully, particularly in terms of how it will affect day-to-day workflows and incident-to reporting responsibilities.

Before stepping into the 2026 change, it helps to revisit where we stand today. Under current 2025 guidance, direct supervision for incident-to requires the physician to be onsite and in the same general working area. Over the years this has been interpreted with remarkable rigidity.

In multi-story buildings, the supervising physician is expected to remain on the same floor. In large medical complexes, they must stay within the immediate, defined proximity of the clinical space. These long-standing physical-location expectations have shaped how practices structure their day.

And now, all of that is about to shift.

As we move from the historical framework into what supervision will look like going forward, it becomes useful to look directly at how CMS chose to define this change. CMS states:

“We are also finalizing, for services that are required to be performed under the direct supervision of a physician or other supervising practitioner, to permanently adopt a definition of direct supervision that allows the physician or supervising practitioner to provide such supervision through real-time audio and visual interactive telecommunications (excluding audio-only). Except for services that have a global surgery indicator of 010 or 090, we are finalizing that a physician or other supervising practitioner may provide such virtual direct supervision for applicable incident-to services under § 410.26, diagnostic tests under § 410.32, pulmonary rehabilitation services under § 410.47, cardiac rehabilitation and intensive cardiac rehabilitation services under § 410.49.”

In practical terms, this means Medicare now allows direct supervision to be satisfied through a live audio and video connection. The supervising physician does not have to be physically in the office, but they must be able to connect immediately via audio and video if their involvement becomes necessary.

A phone call alone will never meet this requirement. The technology must allow both the supervising practitioner and the mid-level provider to see and hear one another in real time so that the physician can intervene without delay if the situation warrants it.

This change does align with what some commercial payors have allowed for years, as many have long permitted electronic access to meet their own direct supervision requirements. However, those payors often do not require both audio and video components. CMS has taken a stricter stance by specifying that direct supervision must involve a real-time audio and visual connection, not audio alone.

While this flexibility modernizes the supervision framework and offers new operational options for practices, CMS guidance stops short of addressing several practical limitations. There is no clarification on geographical boundaries. CMS does not specify whether the supervising practitioner must remain within the United States or within a particular time zone. It does not comment on whether supervision can occur while traveling or on vacation.

These gaps leave us with only the foundational rule: the supervising practitioner must be immediately available.

And that brings us to the practical takeaway. Being available on paper is not the same as being available in real life. If a physician is on vacation halfway across the world and asleep during the clinic’s operating hours, it is difficult to argue that they are immediately reachable.

Likewise, if they are in the middle of a procedure, scrubbed in, and unable to break away, availability is not truly met simply because someone could hold up a device for them. Direct supervision requires that the practitioner can step in promptly should the clinical situation demand it, even under a virtual model.

So while the rule provides new flexibility, it does not remove the responsibility that defines supervision. Practices will still need to decide how to operationalize this in a way that protects patient care and meets the integrity of the requirement.

Some may choose to limit virtual supervision to predictable schedules or defined windows. Others may adopt internal policies clarifying when virtual supervision is and is not appropriate.

For physicians, nurse practitioners, physician assistants, and practice managers, this is a change worth welcoming—but only after the practice takes the time to understand what it means operationally. That includes identifying risks, defining responsibilities, and putting the right policies and procedures in place.

This expansion opens the door to options that were previously off the table, but only when used with sound clinical judgment and a clear plan. As always, strong documentation, clear roles, and well-defined internal expectations will determine whether this flexibility becomes a compliance strength or a liability.

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