The ACC Corner: Appropriate Use Criteria, Accreditation Key to Improving Imaging Services

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Janet Wright, MD, FACC
Much attention in recent years has been focused on the growth in imaging volume in the U.S., especially the rise in tests performed in outpatient office settings. While in reality, the rate of imaging volume growth in Medicare has been slowing since 2005 and imaging spending dropped significantly from 2006 to 2007, there are ongoing attempts at both the state and national level to eliminate or severely limit the ability of cardiologists to provide diagnostic imaging services in their offices.

The ACC strongly supports the ability of specialty physicians, who have knowledge of specific organ systems and disease states, as well as of their patients’ needs, to provide timely and convenient access to imaging services. For this reason, the college has long advocated for improving the use of imaging services through appropriate use criteria (AUC) and accreditation.

AUC define when and how often it is reasonable to perform a given procedure or test. When systematically implemented, AUC may be used to assess patterns of care in an effort to understand and improve the rate of clinically appropriate imaging, while reducing clinically inappropriate tests. The results are reductions in unwarranted variation, potential cost savings, fewer disparities and a higher quality of healthcare.

Accreditation provides an independent and transparent evaluation of imaging facilities and allows laboratories to demonstrate their accountability and high standards. It also can help reduce inappropriate imaging by partnering with ordering clinicians to reflect on AUC patterns and serving as a barrier to entry for new imaging labs that otherwise would not meet standards set by accrediting bodies.

In 2008, Congress enacted the “Medicare Improvements for Patients and Providers Act” (MIPPA), which requires that providers furnishing the technical component of advanced imaging services (MRI, CT and nuclear medicine) be accredited by a designated accreditation organization for purposes of reimbursement as of Jan. 1, 2012. The law does not apply to providers who are paid through the hospital outpatient system.

Earlier this year, Medicare announced the three approved accreditation organizations—the Joint Commission, the American College of Radiology and the Intersocietal Accreditation Commission (IAC). Most people are familiar with the first two organizations, but may be less familiar with the IAC.  The IAC is a joint organization of medical specialty societies, including the ACC, that has provided accreditation for a number of years.

Under MIPPA, these accreditation organizations will evaluate facilities based on criteria that include:
  • Standards for qualifications of medical personnel who are not physicians and who furnish the technical component of advanced diagnostic imaging services;
  • Standards for qualifications and responsibilities of medical directors and supervising physicians, including standards that recognize the specific considerations for the evaluation of medical directors and supervising physicians;
  • Processes to ensure that equipment meet performance specifications;
  • Standards that require the supplier have processes in place to ensure the safety of imaging providers and patients;
  • Standards that require the establishment and maintenance of a quality assurance and quality control program by the supplier that is adequate and appropriate to ensure the reliability, clarity and accuracy of the technical quality of diagnostic images produced by such supplier.

While there is still a year and a half before accreditation requirements begin, the ACC is urging practices to begin addressing the issue now, as it may take some time for the accreditation to be completed. In addition, practices should consider the costs of the accreditation itself, as well as potential changes in personnel needed to accommodate this accreditation, as they budget for future years and consider whether they wish to continue to offer in-office imaging in advanced modalities.

MIPPA also requires CMS to undertake a demonstration program related to appropriate use of advanced diagnostic imaging services. This demonstration program is scheduled to begin in sometime this year. The ACC plans to work with partners to engage in the CMS demo.

In addition, the ACC recently launched a new learning community, called “FOCUS,” that is based on helping imaging providers best implement AUC at the point of care and ultimately reduce inappropriate imaging ( The goal is to share and develop tools that can engage physicians and imaging laboratories in shared responsibility for judicious use of imaging services.

Dr. Wright is the ACC’s senior vice president for science and quality.