This article does not apply to accreditation in radiation oncology.
All interpreting physicians, medical physicists (or MR scientists) and technologists (including part-time and locum tenens staff) must meet and document specific requirements in order for their facility to be accredited by the ACR. Interpreting physicians, medical physicists and technologists working in mammography must also meet Mammography Quality Standards Act (MQSA) qualifications. Detailed requirements are provided for specific personnel roles by modality.
All facilities must maintain detailed supporting documentation regarding their personnel’s training (i.e., type, in what capacity, under whose direction, when, and at what institution).
Under the Medicare Improvement for Patients and Providers Act of 2008 (MIPPA), all facilities that bill for advanced diagnostic imaging services (Breast MR, MRI, CT, PET and Nuclear Medicine) must have a formal procedure to verify employee credentials (primary source verification). Most state licensing and certifying bodies provide the ability to verify an individual’s credentials online (e.g.: http://www.mbp.state.md.us/bpqapp/). Physician certification can be verified at the American Board of Medical Specialties website. These facilities must also verify that personnel are not included on the Office of Inspector General’s (OIG) exclusion list. Technologist credentials can be verified with the relevant certifying agency (e.g. https://www.arrt.org/). Board certifications for medical physicists can be verified with the CRCPD National QMP Registry. ABR certifications can also be verified with the American Board of Medical Specialties. For medical physicists qualifying under the "Not Board Certified in Required Subspecialty" criteria, the primary source should be the accredited educational institution granting the "graduate degree in medical physics, radiologic physics, physics, or other relevant physical science or engineering discipline." The procedure does not need to be submitted to the ACR; however, if the ACR or CMS does a site visit, they will expect to see the written (or electronic) version of the procedure.
The practice site president/CEO or owner must agree that no imaging procedures will be performed by anyone who does not meet accreditation qualifications. The practice site must maintain on-site an updated list of all physicians, medical physicists (or MR scientists) and technologists. Unannounced site visits will be conducted and all information submitted for accreditation will be verified at that time. If the practice site’s supervising physician or president/CEO or owner changes, the site must submit a new Survey Agreement to the ACR.
Documentation and Maintenance of Certification (MOC): The best way an ABR diplomat can document the requirement for the MOC pathway for continuing experience and education is by taking a screenshot of his/her ABR personal database (homepage). This page summarizes the MOC status, including a list of enrollments (certificates), payment status, licenses by state and expiration date, CME and SAMS, cognitive examination, and indication of compliance in PQI. Radiologists certified before 2002 have a lifetime certificate and are not required to participate in MOC; however, if a radiologist voluntarily participates in MOC, he or she would qualify under the MOC pathway.
Revision History for this Article |
Date | Section | Description of Revision(s) |
12-12-19 | All | Article created; FAQs incorporated; No criteria changes |
Changes in Facility or Personnel: Radiation Oncology