Revision History


Mammography requirements differ and are presented separately.


To verify that accredited facilities maintain consistent quality during the 3-year accreditation period, on-site surveys may be performed for each modality without prior notification. The ACR reserves the right to conduct on-site surveys either before or after accreditation. These surveys provide an excellent opportunity for a positive educational exchange with experts in the field, as well as validating information submitted for accreditation. Radiologist and medical physicist (if applicable) reviewers from the accreditation program may be members of the survey team, along with ACR staff.


The Medicare Improvements for Patients and Providers Act (MIPPA) requires that all outpatient facility providers of CT, MRI, breast MRI, nuclear medicine and PET exams that bill under Part B of the Medicare Physician Fee Schedule be accredited in order to receive payment for the technical component of these services. The ACR’s site surveys validate compliance with accreditation criteria.


To be prepared for site surveys, make sure all personnel, including supervising physician and facility administrator, are updated and correct in ACRedit or ACRedit Plus, as applicable.


The following items are typical deficiencies noted during an onsite survey: 

  • Policies for primary source verification, verifying that personnel are not included on the Office of Inspector General exclusion list (MIPPA sites only)

  • Consumer complaint notice providing patient contact information for the ACR (MIPPA sites only)

  • Documentation of initial qualifications, continued education and continued experience for the interpreting physician and medical physicist. Self-documentation is not acceptable.


An ACR Accreditation Facility Tool Kit and other pertinent forms are available for use can be found on the Validation Site Survey ACR webpage. They will assist in gathering and maintaining the documentation that is required for accreditation and will be reviewed during the survey. We strongly advise sites to use these documents to gather and organize information for site surveys.


Submit questions about validation site surveys and all corrective action to vss@acr.org.


Please note that Radiation Oncology is the only modality for which an on-site survey is conducted as part of the accreditation process. Information about on-site surveys for radiation oncology is available here.



Revision History for this Article

Date

Section

Description of Revision(s)

12-12-19

All

Article created; FAQs incorporated; No criteria changes



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