Nuclear Medicine


Nuclear Medicine & PET Accreditation Program FAQ

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Application

Will nuclear medicine/PET accreditation become mandatory?
Effective January 1, 2012, all providers that bill for CT, MRI, breast MRI, nuclear medicine and PET under part B of the Medicare physician fee schedule must be accredited in order to receive reimbursement for the technical component from Medicare. In addition, a number of other payers are now requiring accreditation. Please check with your local carriers.

Is my hospital required to be accredited under the new MIPPA legislation?
No. Part B of the Medicare physician fee schedule is for outpatient facilities. 

What is the cost of nuclear medicine/PET accreditation?
Nuclear medicine accreditation fees are as follows: $1300 per facility, plus a per-unit fee based on the number of modules per unit: one module - $700, two modules - $1400, three modules - $2100.

PET accreditation fees are as follows: $1300 per facility, plus a per-unit fee based on the number of modules per unit: one module - $700, two modules - $1400, three modules - $2100.

Can mobile nuclear medicine/PET practices apply for accreditation? 
If a mobile unit is owned and operated by a single entity, it must have its own supervising and interpreting physicians in order to be accredited as one facility. If a mobile unit is owned by a single entity and services multiple sites with different supervising and interpreting physicians, the unit must be accredited as separate facilities.

How much time do I have to return the testing package to the ACR? 
The testing materials are due 45 calendar days from the date the testing materials were mailed to your facility. After you apply for accreditation, you will receive all of the testing materials and labels. The due date is printed on the labels you receive. If you have elected to submit images electronically, you will receive an email with the due date. The 45-day timeframe is to make sure your facility gets through the accreditation process in a timely manner. If your facility needs extra time, please call ACR accreditation at 1-800-770-0145 to ask for an extension.

Do sites have to submit images within a certain time frame?
Sites are given 45 days to complete the testing portion of the accreditation process. No images will be accepted for review that predate the application by more than six months.

Do facilities have to undergo a site survey as part of the accreditation process?
The accreditation process is conducted primarily by mail. The ACR and/or CMS will conduct site visits with no prior notification to validate maintenance of accreditation criteria within the three year accreditation period.

What options does a site have if it fails the initial test cycle? 
Facilities that do not meet the initial evaluation criteria will only be required to resubmit the procedure that was deficient. Facilities that re-apply after deficiency are required to submit their request for re-application, along with the fee of $600 per module within 15 days of their report.

My facility did not pass accreditation. May we appeal the decision? If so, what's involved?
Facilities that receive a deficiency or a failure may appeal the determination in writing within 15 days of the date of the final report. You must send the original images for all of the submitted cases in the category that did not pass along with a letter describing your reason for appealing. Only those images from the original exam will be considered during the appeal evaluation. These will be forwarded to an arbitrator who did not participate in the initial review with a copy of the previous reviews and the appeal letter written by the facility. No other images will be sent to the reviewer for consideration in the evaluation. The arbitrator's determination will be final.

We recently appealed an adverse accreditation decision. When should we receive the results of the appeal?
You should receive the appeal results within 30 to 45 days of the date all required appeal materials were received by the ACR.

Do all units in the facility need to be evaluated? 
Yes, in order to be accredited, a facility must have all units evaluated and approved. Clinical and phantom images must be submitted for each unit.

Moved Facilities/Adding Units

How does a facility add a new unit to its existing accreditation? 
Log on to your ACRedit home page at https://acredit.acr.org, click on My Modalities then click Units/Modules. Click Add New Unit under the list of units; this will add the unit to the modality ID for that location.

Note: If less than 13 months remains on the accreditation, the facility will start an early renewal. All units currently performing diagnostic testing will be included on the application. Early renewal requires full application fees and complete phantom and clinical testing for each unit. The expiration date for all units will be three years from the current expiration date. If more than 13 months remains on the accreditation, the facility has the option to submit a New Unit Addendum, or a New Unit Reinstate application.

New Unit Addendum: The facility will need to submit complete phantom and clinical testing for the new unit. The facility will pay a reduced accreditation fee. The added unit(s) will receive the same expiration date as currently approved units for this modality.

New Unit Reinstate: The facility will submit complete phantom and clinical testing for all active units. Withdrawn units may also be removed. This application requires full application fees. The expiration date will be three years from the first approval report date.

How do we add a module/isotope to our existing application? 
Log on to your ACRedit home page at https://acredit.acr.org, click on My Modalities then click Units. Click the Add Module/Isotope link associated with the unit you wish to add the module/isotope to.

We will be moving our nuclear medicine/PET facility to a new address. Do I need to provide any information to the ACR? 
Log on to your ACRedit home page at https://acredit.acr.org and click on My Modalities. Click Modality Details link for the site you wish to relocate, and click the Change button next to the location address. The online accreditation system will prompt you for additional information. The site will have to submit phantom testing for any unit that is relocated.

Personnel

Must all nuclear medicine technologists be formally trained or is on-the-job training acceptable? 
Nuclear medicine technologists must have current registration by ARRT(N), NMTCB, or the equivalent state license or must have successfully completed a training program in nuclear medicine, with documentation.

Testing

May we use a model or a volunteer to obtain clinical images to submit for accreditation?
No. Any clinical image submitted for accreditation review must be of an actual patient who needed the examination. Use of volunteers or models, including staff from your facility, is prohibited and may result in withholding, denial or revocation of accreditation. Attempting to “pass off” images taken from a volunteer or model as clinical images from a patient may constitute fraud.

Is direct supervision by a qualified medical physicist required for the performance of the acceptance test and annual tests? 
No. A qualified medical physicist may perform the tests. However, the acceptance test and annual test may be performed by a qualified nuclear medicine technologist or medical physicist-in-training using specific testing protocols developed and approved by the qualified medical physicist. The test results must be reviewed by the qualified medical physicist and documented in the annual survey report.

Can abnormal studies be submitted? 
Submission of normal studies is desired for the nuclear medicine modules; however, abnormal studies may be submitted if no high-quality normal studies are available. The PET module requires that at least one abnormal study be submitted per sub module.