CMS SOM App. A, Tag A-0546

(1) A qualified full-time, part-time or consulting radiologist must supervise the ionizing

radiology services and must interpret only those radiologic tests that are determined by the

medical staff to require a radiologist’s specialized knowledge. For purposes of this section,

a radiologist is a doctor of medicine or osteopathy who is qualified by education and

experience in radiology.

Interpretive Guidelines §482.26(c)(1)

The regulation defines a radiologist as a doctor of medicine (MD) or doctor of osteopathy (DO)

who is qualified by education and experience in radiology. The medical staff must establish the

specific criteria related to education and experience that must be met in order to be privileged as

a radiologist in the hospital.

Ionizing radiologic services offered throughout the hospital must be under the supervision of a

radiologist, who may be part-time, full-time, or consulting. This may be accomplished in several

ways, including by having one organized radiologic service under the direction of the

supervising radiologist, or by the governing body ensuring a uniform approach to ionizing

radiologic services that are offered in multiple, separately organized departments of the hospital

which collaborate with the supervising radiologist in developing their department-specific

protocols for ensuring that these services are free from hazards for patients and personnel.

The supervising radiologist, including, if applicable, a consultant who provides such supervision,

must be privileged as a radiologist at the hospital. The extent of radiologic services provided by

the hospital determines whether the supervising radiologist must carry out these responsibilities

full or part-time.

For diagnostic radiologic services using ionizing radiation, policies and procedures must, in

addition to the requirements addressed in other portions of the radiologic services CoP, identify

which types of radiologic tests require interpretation by a radiologist, as opposed to another type

of practitioner holding privileges; the hospital’s medical staff must approve this policy.

When interpretation of radiologic tests (studies) is provided via telemedicine, the radiologist

interpreting the radiological test must be licensed and/or meet the other applicable standards that

are required by State or local laws in the state where the hospital (and, therefore, the patient) is

located. The requirements concerning granting of privileges to teleradiologists are addressed in

the medical staff (§482.22) and governing body (§482.12) Conditions of Participation.

Survey Procedures §482.26(c)(1)

• Review the medical staff privileging criteria for a radiologist. Review the credentialing

and privileging file of the supervising radiologist to verify that he or she meets the

qualifications established by the medical staff and has been granted privileges as a

radiologist.

• If the supervising radiologist is a part-time employee or consultant, ask him/her how

much time/week is spent on supervising ionizing radiologic services.

• Is there any evidence of problems within the radiologic services that suggest lack of

supervision?

• Determine whether the medical staff has reviewed and approved a policy identifying the

types of diagnostic radiologic tests (studies) that require interpretation by a radiologist.

Review records to determine that a radiologist interprets those tests (studies) that have

been designated.