In the hospital outpatient setting, covered radiation therapy services require the direct
supervision of a physician or qualified non-physician practitioner. In the hospital outpatient
setting, direct supervision means that the physician or non-physician practitioner must be
immediately available to furnish assistance and direction throughout the performance of the
procedure. It does not mean that the physician or non-physician practitioner must be present in
the room when the procedure is performed.
The Code of Federal Regulations (CFR) states that the physician must be available to furnish
assistance and direction throughout the performance of the procedure and therefor the
supervising physician or non-physician practitioners is required to have and maintain the ability
to perform the service under supervision according to both hospital-based privileges and state
scope of practice.
While CMS does not specify that radiation therapy services should be supervised by a radiation
oncologist; it is the opinion of the ACR that a board-certified/board-eligible radiation
oncologist is the clinically appropriate physician to supervise these procedures. This position is
supported by guidance from the Conference of Radiation Control Program Directors (CRCPD)
training requirements for therapeutic radiation machines, which closely mirrors the U.S.
Nuclear Regulatory Commission’s regulations for teletherapy, sealed source therapy and HDR
after loading brachytherapy. Further, ACR Radiation Oncology Practice Accreditation program requirements specify that “a radiation oncologist should be available for direct care and quality
review and should be on the premises whenever radiation treatments are being delivered. The
radiation oncologist, facility, and support staff should be available to initiate urgent treatment
within a medically appropriate response time on a 24-hour basis or refer to a facility that is
available to treat on a 24-hour basis. When unavailable, the radiation oncologist is responsible
for arranging appropriate coverage.”
In the calendar year (CY) 2010 Hospital Outpatient Prospective Payment System (HOPPS) final
rule, CMS stated that non-physician practitioners (NPP) may directly supervise all hospital
outpatient therapeutic services they may perform themselves within their State scope of practice
and hospital-granted privileges. Included among the list of applicable NPPs are physician assistants and nurse practitioners.
These regulations apply to services performed both on and off campus. More information on the
supervision of therapeutic services in the hospital outpatient setting can be found here.