Statement from Drugs and Contrast Media Committee on Supervision of Contrast Material Administration

This article was originally published February 26, 2024. It was updated effective June 12, 2025.

DISCLAIMER: 

This information is designed to assist practitioners in providing appropriate radiologic care for patients. It does not create inflexible rules or requirements of practice and is not intended, nor should it be used, to establish a legal standard of care. Therefore, the American College of Radiology cautions against using this statement in litigation in which the clinical decisions of a practitioner are called into question. The ultimate judgment regarding the propriety of any specific procedure or course of action must be made by the practitioner considering all the circumstances presented.

---

Direct supervision is required whenever contrast material is administered*. 

This direct supervision requirement can be met by an on-site radiologist, other physician, or qualified licensed practitioner**.

Virtual supervision of qualified on-site personnel should only be performed by a physician.  Only one level of virtual supervision should occur (e.g. an off-site physician cannot supervise an off-site licensed practitioner, technologist, or nurse). The off-site physician must be able to directly communicate in a bi-directional manner with the on-site individual responsible for the safety and placement of the patient while the study is being conducted.

The on-site personnel, who are in addition to the radiology technologist, must include at least one licensed practitioner who:

• Has formal training to include clinical rotations/clinical experience specifically in patient assessment, physical examinations, and administration of medications (beyond contrast media and image enhancing agents) as part of the curriculum for licensure and/or graduation.
• Meets institutional periodic competency guidelines at evaluating patients and diagnosing and differentiating types of adverse reactions to contrast material.
• Is able to recognize when medical intervention is required for allergic/allergic like hypersensitivity reactions or other adverse events due to contrast administration.
• Is trained to administer prescription medications, including IV medications, (e.g., antihistamine, intravenous fluid, beta agonist inhalers, IV or IM epinephrine) and perform other appropriate interventions independently or under a standing orders/algorithmic approach under state law or regulations, and under local, institutional, site, and facility policies, guidelines, and rules. These interventions are those indicated for urgent response to adverse reactions to contrast material as listed in the ACR Manual of Contrast Media or similar local policies or guidelines.
• Is able to consult with the supervising physician within an appropriate timeframe.
• Understands when to call for assistance and how to activate emergency response systems. 

Overall staffing should take into account the timeliness of available emergency response systems and a team approach to crisis management.

---

*Contrast administration includes the standard post administration monitoring as dictated by all federal/state law or regulations and under local, institutional, site, and facility policies, guidelines, or rules. 

**Qualified licensed practitioners may supervise as permitted by federal/state laws or regulations and local, institutional, site and facility policies and guidelines. The licensed practitioner should be able to consult in a timely manner with a radiologist or other physician on patient management and treatment decisions, if questions arise. 

***If “direct” supervision by a physician is performed virtually, the process should comply with all federal/state law or regulations and local, institutional, site, and facility policies, guidelines, or rules related to telemedicine.

Definitions of Supervision Levels:

• Direct Supervision: In the office setting means the physician must be present in the office suite and immediately available to furnish assistance and direction throughout the performance of the procedure. It does not mean that the physician must be present in the room when the procedure is performed.  
  
  • According to the CY 2025 PFS Final rule, CMS will continue to define direct supervision to permit the presence and “immediate availability” of the supervising practitioner through real-time audio and visual interactive telecommunications through December 31, 2025.
• General Supervision: means the procedure is furnished under the physician’s overall direction and control, but the physician’s presence is not required during the performance of the procedure. Under general supervision, the training of the nonphysician personnel who actually performs the diagnostic procedure and the maintenance of the necessary equipment and supplies are the continuing responsibility of the physician.
• Facilities: are defined as any provider (e.g., hospital, skilled nursing facility, home health agency, outpatient physical therapy, comprehensive outpatient rehabilitation facility, end-stage renal disease facility, hospice, physician, non-physician provider, laboratory, supplier, etc.) providing medical services to beneficiaries. 

Personnel who qualify as licensed practitioners per CMS which are relevant in radiology include:

• Nurse Practitioners
• Physician Assistants
• Clinical Nurse Specialists