MRI Accreditation

A. The ACR MRI Accreditation Program is a voluntary process. However, the Centers for Medicare and Medicaid Services (CMS) requires suppliers of the technical component of advanced diagnostic imaging (ADI) services to be accredited by a designated accrediting organization in order to receive Medicare reimbursement. Hospitals and critical access hospitals are not subject to this requirement.

A. Yes. Any facility may apply for MRI accreditation. Small-bore specialty scanners such as Embrace® will utilize the small ACR phantom, provided with the system.

A. Accreditation Fees:

A. 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.

A. Clinical image deficiencies or a combination of clinical and phantom image deficiencies are common sources of failure.

A. Yes. Facilities that receive a deficiency or a failure may appeal the determination in writing within 15 days of the date of the final report. A letter describing your reason for appealing must be submitted. Only those images from the original exam will be considered during the appeal evaluation. These will be forwarded to an arbitrator (a reviewer 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.

A. You may appeal the decision; however, you may only submit the original images. If some sequences from the original exam were not included you may be able to submit those sequences. Please call the Diagnostic Modality Accreditation Information Line at (800) 770-0145 for further guidance on your specific situation.

A.Visit the ACR MRI Accreditation section on the ACR website and read at least the following:

• Accreditation Overview
• Information needed in your application and time requirements
  Clinical Testing Instructions for the Head/Neck See Table 1 in Serrai et al., J Am Coll Radiol 2018;1: 1022-1026).
• Small Phantom Testing Instructions

After reading these documents and checking your protocols, you can apply online at ACRedit.

A. Everyone at your facility should be involved with accreditation. Your “core team” should be made up of the following personnel:

1. Your lead MRI technologist will be the main person ACR might contact if necessary. This should be the primary person who completes accreditation forms and documents and is the technologist contact listed on your application.

2. Your MRI supervising physician is the interpreting physician responsible for your MRI protocols, and approves all aspects of the testing materials submission before you send them to the ACR for review.

3. Your Medical Physicist/MR scientist should be responsible for reviewing your facility’s weekly QC and the annual system performance evaluation. They may also be involved with the phantom portion of your testing materials submission and assist the supervising physician and lead technologist with technical questions about your routine clinical protocols.

4. Your administrative contact, such as the manager, director, etc., will help organize the members of your “core team”, and ensure that everyone on the team has the resources necessary to successfully complete your accreditation process.

A. The testing materials are due 45 days from the date the testing package link was made available to your facility upon the submittal of your application. The time frame is based on calendar days. After you apply for accreditation, you will receive all of the testing materials electronically. 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 an ACR accreditation representative at (800) 770-0145 and ask for an extension.stem.

A. The accreditation process is conducted primarily by mail. The ACR and/or CMS will conduct site visits without prior notification to validate maintenance of accreditation criteria within the three year accreditation period.

A. Sites have options such as appealing the results, if they disagree with the findings based on the information submitted, or reapplying for the deficient areas indicated on the final report. For clinical examinations: repeat those examinations on a different patient. For phantom images, repeat the phantom scans (we recommend with the assistance and supervision of a qualified medical physicist/MR scientist).

A. You should receive the appeal results within 30 to 45 days of the date all required appeal materials were received by the ACR.

A. Although you may appeal the decision, you may not submit new cases. During accreditation review, the ACR reviewers assume that the submitted cases were reviewed by the modality’s supervising physician and are examples of your best work. Consequently, during an appeal, only the original images will be considered.

A. 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.

A. Yes, a homogeneity test of some kind is required as part of the annual system performance evaluation for all accredited magnets, and those applying for accreditation. The ACR QC Manual describes this in the Medical Physicist’s/MR Scientist’s section.

A. Sites applying for MRI accreditation must submit an annual MRI system performance evaluation performed by a Medical Physicist or MR scientist. The Medical Physicist/MR Scientist will follow the ACR MRI Quality Control Manual in order to perform a complete annual system performance evaluation. This evaluation includes an evaluation of the weekly QC performed by a technologist. A technologist may still perform the ACR phantom portion of the accreditation submission but it is strongly recommended the images be reviewed by your Medical Physicist/MR Scientist prior to submission to ensure they meet ACR specifications.

A. If no laser film printer is connected to the EMBRACE system, no weekly laser film printer quality control need be performed.

A. Yes, SNR is an acceptable alternative to LCD scoring for daily/weekly phantom QC. However, LCD scores must be included in the Annual System Performance Evaluation.