CT Accreditation History & Useful Tips to Ensure Optimal Outcomes with Accreditation Process

1. CT Accreditation History & Useful Tips to Ensure Optimal Outcomes with Accreditation Process

2. Red=MIPPA definition of advanced diagnostic imaging (ADI)

3. Factors Affecting the Growth of Accreditation 1. Reimbursement – Federal Mandate MIPPA 2008 Affects “advanced imaging” (Nuclear, PET, MRI, CT) in outpatient setting (not hospitals) Accreditation required by 1/1/2012 120 day CMS grace period for adding new sites or additional imaging modality 2. Reimbursement – Private Insurers United Healthcare (Affects “advanced imaging” – MRI, CT, PET, nuclear medicine plus echocardiography) Various other private insurers and RBMs

4. IAC Application Receipt by Division UHc Req MIPPA

5. Additional Payment Policies • California • California Senate Bill 1237 Requires CT Facilities Be Accredited by July 1, 2013 • Commencing July 1, 2012, a person that uses a computed tomography (CT) X-ray system for human use shall record the dose of radiation on every CT study produced during a CT examination • Minnesota • MN Bill HF 2276 :Any facility that performs advanced diagnostic imaging services (MR, CT, Nuclear/PET) must obtain accreditation by August 1, 2013. • Thereafter, all facilities that provide advanced diagnostic imaging services in the state must obtain accreditation prior to commencing operations and must, at all times, maintain accreditation with an accrediting organization

6. IAC CT Standards • Organization • Examinations and Procedures • Quality Improvement

7. Areas of CT Accreditation • coronary calcium scoring CT • coronary CTA • neurological CT [brain, spine, CTA] • sinus and temporal bone CT • body CT [chest (non-coronary), abdomen, pelvis, extremity] • vascular/other CTA [chest (non-coronary), abdomen, pelvis, peripheral/extremity]

9. IAC CT|ICACTL Statistics Accredited CT labs: 469 Accredited CT sites: 574 Testing Areas Currently Granted Accreditation CCS 73 (15.57%) CCTA 71 (12.37%) NCT 120 (25.59%) STB 351 (61.15%) WBCT 173 (36.89%) Other CTA 95 (16.55%)

10. Application Decisions Grant Valid for three years from date of decision Delay Issues related to quality identified Notification letter outlines deficiencies and additionally required information Accreditation will be granted once issues are corrected Lab will have one year to correct deficiencies Site visit Unable to make decision based on written application

11. Lessons Learned – Tips for Success Create a culture of quality Start early (6-12 months) Be familiar with the accreditation guidelines Design policies that meet IAC Standards Buy-in from all staff and physicians before starting Involve key staff and physicians

12. Lessons Learned – Tips for Success Physicians Help understand rationale Select a physician champion Review policies Start early-provide feedback Understand compliance is mandatory Consider tying accreditation to privileging CME’s – Category 1 AMA or equivalent specific to the CT

13. Lessons Learned – Tips for Success One staff champion, but involve staff in acquiring the data Have policies and procedures in place before acquiring studies Keep a running collection of perfect studies Clinical correlation or peer review QA required

14. Common Pitfalls Not giving yourself enough time Not pre identifying abnormal studies Not sending in your best cases Not having physician/staff modality specific CME’s Not addressing previous deficiencies Not having QA documentation

15. Reporting Reporting requirements are detailed Compliance with IAC CT reporting requirements Reports need to be near PERFECT Compliant with the Standards Complete Interpretation reflects study findings

16. 6021 University Boulevard, Suite 500 Ellicott City, MD 21043 Phone: 800.838.2110 Fax: 800.581.7889 Mary Lally, MS, RT(R)(MR) Director CT Accreditation lally@intersocietal.org Nancy Merrill, RT(R)(M)(CT) nmerrill@intersocietal.org Brandy Mertz Accreditation Coordinator mertz@intersocietal.org How to Contact IAC CT|ICACTL: