Rad onc supervision, the epilogue

[dozitgetchahi]

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That's pretty benign compared to the stuff I've seen out West LOL

If you can find worse than that in America, I don’t want to go anywhere near it.

 

[thecarbonionangle]

Oh totally agree with all of this. I didn’t train in the south and thus was seen as an “outsider” for the entire time I was there. Even though I was a demonstrably better physician than almost everyone I encountered. Btw some of the patients (the ones with their heads screwed on straight-er) actually want doctors trained elsewhere because they know the locals totally suck.

Oh, and BTW: several of the senior docs in my practice were members of the local KKK chapter. No joke. At least one doc was drinking and doing drugs while seeing patients, and the state board raided his office shortly after I left. One doc was living out of his office (had a wife and kids in a neighboring state but was working here?) and apparently had used condoms under his desk all the time. Another had been groping patients and had a “gentleman’s agreement” with the practice to see his patients virtually through a robotic camera, because he was one of the biggest billers in the practice and we just can’t let him go, can we? Bless his heart (I hope to never hear that phrase again lol). I seriously wish I was joking about all this. It was a total all American ****show. The practice imploded not long after I left, and I moved back to the Midwest where I belong.

Used condoms under desk? They were sleeping with nurses?

 

[dozitgetchahi]

Used condoms under desk? They were sleeping with nurses?

I think he was bringing random women into his office at night (since it was his “apartment” of sorts, he had a bed in there and was living there)

 

[medgator]

CMS 1, ASTRO circa 2020-2024 0

From the latest CMS 2026 fee schedule:

CMS is also proposing 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, CMS is proposing 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.

 

[TheWallnerus]

CMS 1, ASTRO circa 2020-2024 0

From the latest CMS 2026 fee schedule:

Kind of… ironic. I think that’s the right word.

Prior to the 1980s the term “radiation oncologist” didn’t really exist. And the “radiation therapists” definitely definitely definitely didn’t worry about supervision.

In the 1980s the term rad onc was ABR sanctified. And still radiation oncologist supervision definitely definitely was not a worry.

It will still not a worry in the 1990s.

Come -2005, it began to be a HOT worry. The next 15 years were marked by supervision agita and you had people like Ken Olivier saying on Twitter that cancer patients always *deserve* to have a rad onc on site at all times no matter what. And people being shamed for not being on site. Etc etc. Nowadays Ken seems more interested in psychedelics that supervision. How nice.

Fast forward to 2026. Where we are essentially back to the 1990s and decades prior. Makes one very tired.

 

[medgator]

Come -2005, it began to be a HOT worry. The next 15 years were marked by supervision agita and you had people like Ken Olivier saying on Twitter that cancer patients always *deserve* to have a rad onc on site at all times no matter what. And people being shamed for not being on site. Etc etc. Nowadays Ken seems more interested in psychedelics that supervision. How nice.

Must be celebrating

 

[RickyScott]

Must be celebrating

I would sooner be a fellow of NAMBLA than ASTRO

 

[CurbYourExpectations]

I would sooner be a fellow of NAMBLA than ASTRO

dude

 

[drowsy12]

I would sooner be a fellow of NAMBLA than ASTRO

Yo what lol

 

[alwaysbeIMRTing]

South Park circa 2000 offending zoomers. I feel old.

 

[yesmaster]

I hope I have more to celebrate at age 50 than getting a few more capital letters after my name.

 

[CaesarRO]

Kind of… ironic. I think that’s the right word.

Prior to the 1980s the term “radiation oncologist” didn’t really exist. And the “radiation therapists” definitely definitely definitely didn’t worry about supervision.

In the 1980s the term rad onc was ABR sanctified. And still radiation oncologist supervision definitely definitely was not a worry.

It will still not a worry in the 1990s.

Come -2005, it began to be a HOT worry. The next 15 years were marked by supervision agita and you had people like Ken Olivier saying on Twitter that cancer patients always *deserve* to have a rad onc on site at all times no matter what. And people being shamed for not being on site. Etc etc. Nowadays Ken seems more interested in psychedelics that supervision. How nice.

Fast forward to 2026. Where we are essentially back to the 1990s and decades prior. Makes one very tired.

Mostly to be pedantic... But there were some important changes that you kinda gloss over in that timeline.... Namely advent of IMRT and CBCT.

You can (and do) argue we don't need direct supervision anymore for those, but it is a germane reason for Astro to be worried about it circa 2005

 

[RickyScott]

Mostly to be pedantic... But there were some important changes that you kinda gloss over in that timeline.... Namely advent of IMRT and CBCT.

You can (and do) argue we don't need direct supervision anymore for those, but it is a germane reason for Astro to be worried about it circa 2005

Why is imrt germane?

 

[CaesarRO]

It's a little different as far as setup and accuracy goes than seeing up a 2D or 3D field? Having the doc around for therapists to grab if needed would be a valid concern. Especially as doses began increasing dramatically.

Again. We know a lot more now than we did then. But I think it's disingenuous in his narrative to pretend it came out of thin air in 2005

 

[TheWallnerus]

It's a little different as far as setup and accuracy goes than seeing up a 2D or 3D field? Having the doc around for therapists to grab if needed would be a valid concern. Especially as doses began increasing dramatically.

Again. We know a lot more now than we did then. But I think it's disingenuous in his narrative to pretend it came out of thin air in 2005

There has been one IGRT code in the history of rad onc that had a personal supervision requirement. Which was it, when did it appear, and which code did it replace? Anyone who knows that can then rightfully add nuance to my disingenuous timeline 😉

Bonus if you know the legal/CMS status of supervision prior to the IMRT era. (Hint: the IMRT era did not change those requirements. Nor did the CBCT era.)

Of course nothing comes out of thin air. In medicine, in rad onc, it’s usually mostly about… the money.

 

[Ray D. Ayshun]

So, to confirm, is anyone approving imaging while on vacation, billing 77014, and not worried about an audit?

 

[TheWallnerus]

So, to confirm, is anyone approving imaging while on vacation, billing 77014, and not worried about an audit?

Yes. “Vacation” is the superfluous noun in your sentence.

 

[Ray D. Ayshun]

Yes. “Vacation” is the superfluous noun in your sentence.

While in a different time zone then. And if so, what allows it? The language suggests that while this may not need to happen in person while patient is on the machine, it should at least occur in the same zip code.

 

[alwaysbeIMRTing]

We are told that we cannot check images and bill 77014 if we are doing so from a computer that is outside of US territories. Same reason radiologists can read in Puerto Rico but not Jamacia.

 

[Ray D. Ayshun]

We are told that we cannot check images and bill 77014 if we are doing so from a computer that is outside of US territories. Same reason radiologists can read in Puerto Rico but not Jamacia.

Lol. I wasn't even thinking about remote rads.

 

[TheWallnerus]

We are told that we cannot check images and bill 77014 if we are doing so from a computer that is outside of US territories. Same reason radiologists can read in Puerto Rico but not Jamacia.

*Citation needed

EDIT: what if you aren’t in any definable territory? How much trouble will you be in then?

 

[udrag14]

So, to confirm, is anyone approving imaging while on vacation, billing 77014, and not worried about an audit?

The case was not location but that the person never opened the images.

There is another weird nuance if licensing also come into play if you are in a different state.

 

[Bequerel]

What if your VPN says you’re in the USA or you remote into your desktop to approve (I’m joking..kinda)? I also want to see a citation because it’s hard to believe an audit is going to look into where you approved it from. Date and time yes but location seems far fetched.

 

[Doctorer]

What if your VPN says you’re in the USA or you remote into your desktop to approve (I’m joking..kinda)? I also want to see a citation because it’s hard to believe an audit is going to look into where you approved it from. Date and time yes but location seems far fetched.

If you’re at the point where they’re subpoenaing vpn records you’ve probably gone too far.

 

[alwaysbeIMRTing]

You mean to tell me there are radiologists out there living in Vietnam for $20 a day COL earning 1M nighthawking in the US during daylight hours in the far east with a VPN or US based cell phone hotspot that routes through a US data center? No way, don't believe it. Nobody would do something so rotten.

 

[udrag14]

You mean to tell me there are radiologists out there living in Vietnam for $20 a day COL earning 1M nighthawking in the US during daylight hours in the far east with a VPN or US based cell phone hotspot that routes through a US data center? No way, don't believe it. Nobody would do something so rotten.

There is no federal law that prevents this. Maybe your hospitals IT department would have issues.

 

[BobbyHeenan]

There is no federal law that prevents this. Maybe your hospitals IT department would have issues.

You mean to tell me there are radiologists out there living in Vietnam for $20 a day COL earning 1M nighthawking in the US during daylight hours in the far east with a VPN or US based cell phone hotspot that routes through a US data center? No way, don't believe it. Nobody would do something so rotten.

Even nearly two decades ago during intern year we had a U.S. trained nighthawk living in Australia reading inpatient CT's/MRI's for us. I had to call him when I was on night float.

I think this thing definitely goes on.

 

[OTN]

That’s why I always check my films on my laptop in the waiting rooms of the US embassy if I’m traveling abroad.

 

[TheWallnerus]

We are told that we cannot check images and bill 77014 if we are doing so from a computer that is outside of US territories. Same reason radiologists can read in Puerto Rico but not Jamacia.

There is no federal law that prevents this. Maybe your hospitals IT department would have issues.

Even nearly two decades ago during intern year we had a U.S. trained nighthawk living in Australia reading inpatient CT's/MRI's for us. I had to call him when I was on night float.

I think this thing definitely goes on.

Do any of you recall when there were departments and rad oncs that existed that said you had to stand at the machine for CBCTs. That requirement, for sure, never existed for CBCT. There were departments that said the MD had to be at the console for every SBRT fraction. And so on and so forth. Rad oncs (and rad onc billers and coders) have a unique ability in medicine to synthesize apocryphal Medicare rules.

 

[TheWallnerus]

Do any of you recall when there were departments and rad oncs that existed that said you had to stand at the machine for CBCTs. That requirement, for sure, never existed for CBCT. There were departments that said the MD had to be at the console for every SBRT fraction. And so on and so forth. Rad oncs (and rad onc billers and coders) have a unique ability in medicine to synthesize apocryphal Medicare rules.

I shouldn't have been so flippant. Indeed there is a law about telerads and outside the U.S.!

At first ChatGPT thought 77014 can't be "read" from outside the U.S. However, it seemed convince-able it was possible. Take that for what it's worth.

ChatGPT - Remote 77014 image review

Shared via ChatGPT

chatgpt.com

Compliance Position Paper
Interpretation of Imaging Studies Under Medicare When Performed by U.S.-Affiliated Physicians Temporarily Outside U.S. Territory

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Background
Medicare reimbursement policy restricts payment for medical services performed "outside the United States," as defined in CMS Pub. 100-02, Chapter 16, Section 60. The text specifically prohibits payment for services "subcontracted to another provider or supplier located outside the United States," citing an example where a radiologist practicing in India interprets U.S.-based imaging. The implication of the policy is often interpreted by CMS and MACs to mean that any portion of a service (including professional interpretation) performed while physically located outside U.S. territory is not eligible for reimbursement.

However, the regulation’s literal language focuses narrowly on the subcontracting of services to providers located outside the U.S., rather than the physical location of a U.S.-licensed and U.S.-contracted provider at the time of furnishing the service.

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Key Regulatory Text
CMS Pub. 100-02, Chapter 16, Section 60 states:

"Payment may not be made for a medical service (or a portion of it) that was subcontracted to another provider or supplier located outside the United States. For example, if a radiologist who practices in India analyzes imaging tests that were performed on a beneficiary in the United States, Medicare would not pay the radiologist or the U.S. facility that performed the imaging test for any of the services that were performed by the radiologist in India."

This rule is derived from the general prohibition in SSA §1868(a)(1) against payment for services rendered outside the United States, with certain narrow exceptions.

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Compliance Position

1. U.S.-based Physicians Traveling Abroad
   If a radiologist who is:

• Licensed in the U.S.,
• Contracted/employed by a U.S. provider,
• Using U.S.-based hardware and infrastructure,
• Reviewing studies performed in the U.S.,

performs a professional interpretation while temporarily outside the United States (e.g., on vacation or a short trip), that action does not fall under the language of the rule if the radiologist was not subcontracted as a foreign-based provider at the time of contracting and retains a U.S.-based clinical and billing identity.

1. Textual and Legal Interpretation
   The CMS manual does not define "located" in terms of temporary physical presence versus business registration or professional domicile. The rule as written may be interpreted to prohibit payment only when services are deliberately routed to a non-U.S. provider based abroad (e.g., offshore teleradiology firms). Accordingly, it is defensible to conclude that a U.S.-licensed, U.S.-contracted physician interpreting a study remotely during travel abroad does not violate this regulation, provided all professional and billing relationships remain U.S.-based.
2. Compliance Risk Assessment
   While many MACs interpret this language conservatively, there is currently no express regulatory language that prohibits temporary remote interpretation by a U.S.-based provider traveling internationally. Accordingly, while acknowledging audit risk, the group may take the position that such reads are compliant with a good-faith reading of CMS policy.
3. Recommended Group Policy
   In recognition of this ambiguity and in reliance on a faithful textual reading of CMS guidance:

• Our group will permit Medicare billing for professional interpretations performed by U.S.-based radiologists who are temporarily located outside the United States, provided they maintain U.S. licensure, use U.S.-based infrastructure, and remain fully contracted with the U.S. billing entity.
• Billing staff must document the provider’s credentials and affiliation at the time of service.
• Interpretations for non-Medicare payers are also allowable subject to payer and licensure requirements.

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Conclusion

While CMS has at times enforced this rule conservatively, the regulation itself does not unambiguously prohibit professional interpretations rendered remotely by U.S.-based physicians who are temporarily abroad. Our group concludes that such reads are compliant with the existing language and billing rules when performed in accordance with U.S.-based licensing, infrastructure, and contracting.

This position may be re-evaluated if CMS issues clarifying guidance or revises the relevant manual language.