Why should my laboratory seek accreditation?

The AANEM EDX Laboratory Accreditation Program:

  • Demonstrates clinical excellence in electrodiagnostic medicine
  • Proves a laboratory's commitment to providing the highest quality health care and a safe environment for patients
  • Provides patients, referral sources, and payers with a credible measure to differentiate the laboratory's quality of care

What types of practices can apply for accreditation?

Accreditation is available to all types and sizes of practices based in the United States, including:

  • Private Practices
  • Solo or Group Practices
  • Academic Institutions
  • Hospital Based Practices
  • Independent Diagnostic Testing Facilities

What does the EDX Laboratory Accreditation Program evaluate?

The standards used for accreditation evaluate the diagnostic services and clinical operations essential to providing quality patient care, including clinical staff qualifications and continuing education, the physical facilities, the EDX equipment, protocols for performing EDX studies, patient reports, and the policies in place for ensuring the health and safety of every patient.

Will my ABEM certification be recognized by the accreditation program?

Yes, accreditation with exemplary status is the highest level of accreditation recognized by AANEM. Exemplary status is granted to laboratories where the lab medical directors are certified by at least one of the following boards:

  • American Board of Electrodiagnostic Medicine (ABEM)
  • American Board of Psychiatry and Neurology (ABPN) in Clinical Neurophysiology or Neuromuscular Medicine
  • American Board of Physical Medicine & Rehabilitation (ABPMR) in Neuromuscular Medicine

How long will our lab remain accredited once we achieve the designation?

The AANEM accredits laboratories for a 5-year period. The program is designed to facilitate continuous improvement through periodic reviews to ensure ongoing compliance with accreditation standards.

What is the EDX Laboratory Accreditation Program?

The AANEM EDX Laboratory Accreditation Program is a peer review process that evaluates EDX laboratories against standards developed by AANEM. Achieving accreditation demonstrates that a significant milestone in patient care has been attained.

How much will it cost to apply for accreditation?

The accreditation review fees will be based on the structure of the EDX practice. Each accreditation applicant laboratory will pay the base fee of $1000 for up to three physicians. There is a $200 charge for each additional physician (four physicians or more). Each satellite laboratory applying for accreditation with a main laboratory is $200.

Why will there be a separate charge for accrediting satellite locations?

Rather than require each location to apply independently (which would be more costly and time consuming), a lesser fee is charged that recognizes the crossover of policies, procedures, and staffing that exists with satellite locations.

What will happen after the application is submitted? 

Members of the AANEM Accreditation Committee will review the application and patient reports. If any remediation is necessary, this will be communicated to the contact listed on the Lab Accreditation application. Once remediation is complete, the lab will receive accredited status.

What will happen if a laboratory is denied accreditation?

The goal of the program is education. Laboratories with minor problems will be granted provisional accreditation. The laboratory will have 6 months to resolve any concerns identified by the AANEM Accreditation Committee.

Will there be site visits?

No, site visits will only be performed if the AANEM Accreditation Committee reviewers are concerned about the accuracy of the information submitted in the application.

What is required for accreditation with exemplary status?

Accreditation with exemplary status is the highest level of accreditation recognized by AANEM. To be eligible, the lab medical director(s) must be certified by at least one of the following boards:
  • American Board of Electrodiagnostic Medicine (ABEM)
  • American Board of Psychiatry and Neurology (ABPN) in Clinical Neurophysiology or Neuromuscular Medicine
  • American Board of Physical Medicine & Rehabilitation (ABPMR) in Neuromuscular Medicine
All laboratories that are not eligible for accreditation with exemplary status may apply for accreditation status. If at any time a laboratory becomes eligible for exemplary status, they may contact the AANEM office and request a reevaluation of their status.

The AANEM Lab Accreditation application asks for examples of quality improvement activities my laboratory has engaged in over the last 2 years. What types of activities can demonstrate quality improvement?

Quality improvement generally describes is a process designed to raise the quality of EDX medical services within the laboratory in order to improve the health outcomes of the laboratory’s patients. There are a number of ways a laboratory can demonstrate quality improvement, a few examples include:

  • Distributing patient satisfaction surveys, reviewing the responses, and modifying or implementing laboratory procedures or policies based upon the feedback received
  • Conducting periodic peer review sessions to ensure accuracy of the diagnosis
  • Meeting with colleagues to discuss difficult studies

How do I determine if our laboratory qualifies as a satellite laboratory?

To qualify as a satellite laboratory, (1) the same organizational policies, including medical record retention, human resources, and laboratory procedures must be used, and (2) the individual designated as the laboratory medical director at the main laboratory must also manage the satellite facility. Satellite laboratories not meeting these standards must apply as a main laboratory site.

Does AANEM have a model policy that I can adopt?

Laboratories seeking accreditation from AANEM's Electrodiagnostic Laboratory Accreditation Program must demonstrate a commitment to compliance with all privacy, security and electronic transaction code requirements of the Health Insurance Portability and Accountability Act (HIPAA). In order to demonstrate this commitment, applicant laboratories must submit a HIPAA Compliance Policy with their applications.

AANEM has not created a model HIPAA Compliance Policy. However, there are a number of resources available online, both free and fee-based services, which may help you create a policy that is appropriate for your laboratory. The Agency for Health Care Administration (AHCA) has a comprehensive HIPAA Policy and Procedure Manual available for download on the HIPAA website, which may provide guidance when drafting a HIPAA Compliance Policy for the accreditation program. Please be advised that the AANEM does not warrant that the policies created by the AHCA will be suitable for a laboratory’s particular purposes or comply with any local, state, and/or federal law.

Before adopting a particular policy, an applicant laboratory should be reviewed by an attorney knowledgeable with federal and state privacy laws related to the use and storage of medical records.

AANEM does offer a few other model policies on the Model Policies page.

Does AANEM have any guidance on what is needed for the reports we submit?

Yes. Review AANEM's educational paper, Reporting the Results of Needle EMG and Nerve Conduction Studies. You may also use AANEM's Key Report Checklist and Report Template to help you ensure your reports meet AANEM's standards.

The EDX Laboratory Accreditation Program requires physicians working in the lab to abide by certain continuing education and proficiency requirements, which include completing a minimum of 100 EDX consultations each calendar year. Our lab limits its practice to pediatric patients and does not see enough patients each year for all physicians to conduct 100 EDX consultations. Is our lab eligible for accreditation?

AANEM believes that competency in EDX medicine is achieved by performing and interpreting EDX examinations on a regular basis. AANEM established the 100 EDX consultation requirement in order to ensure physicians in an accredited lab are conducting enough consultations to maintain their clinical and diagnostic skills.

Labs employing physicians who are unable to meet the requirement may request a waiver of the requirement.  The lab medical director must submit a formal waiver request to AANEM detailing the reason(s) why the physician(s) is unable to meet the requirement, the education and certifications of all physicians employed in the lab, and any other pertinent information.

The AANEM EDX Lab Committee will review the request and determine if a waiver is warranted and may, at its discretion, impose further and additional continuing education and/or proficiency requirements in lieu of the 100 EDX consultation requirement.

The requirements for physicians listed on the AANEM EDX Lab Accreditation application include the following:
  • Active primary board certification in neurology or PM&R
  • Active medical license in the state they are practicing
  • 100 EDX medicine consultations in each calendar year (25 consultations for pediatric physicians)
  • Stay on track each year to meet the 25 CME credit requirement during the 5-year accreditation period (~ 5 CME per year)

It has been a long time since we have submitted our accreditation application. When can we expect to hear from AANEM?

We thank you for your continued patience. We aim to have your application reviewed as quickly as possible. Occasionally the process can take up to a couple of months if any items need to be remediated. If you would like a status report of your application, contact accreditation@aanem.org.

Does a satellite laboratory need to apply for its own accreditation?

In order to qualify as a satellite laboratory, the lab must be managed by the same lab medical director as the main lab. The satellite lab must also follow the same policies and procedures as the main lab. If the lab is not managed by the lab medical director or follows different policies or procedures than the main lab, it must apply on its own for accreditation.

Do the technologists who work in the lab need to be certified for the lab to be accredited?

No. While we strongly encourage technologist certification, it is not a requirement for lab accreditation.

What happens if the lab medical director leaves the lab?

Lab accreditation is tied to the facility, much like sleep medicine's accreditation. If the lab medical director were to leave the facility, the facility maintains the accreditation as long as the accreditation criteria is met. The existing lab would need to appoint a new, qualified lab medical director on the application. If the new lab medical director has not previously been a part of the lab's accreditation, the accreditation will be suspended until patient reports have been reviewed and deemed satisfactory. If the new lab medical director was a physician on the accreditation application previously and has had their patient reports reviewed, there would be a seamless transition and no suspension of accreditation. 

Lab medical directors who leave an accredited lab must join another already accredited lab or start a new accreditation application to regain association with an accredited lab.

Accreditation after expiration of accreditation status

All accredited laboratories shall have a 3-month grace period after expiration of their certificate to complete the reaccreditation material. If the reaccreditation materials are completed prior to the expiration of the 3-month grade period, the laboratories will maintain their original certificate number. If a laboratory does not complete the reaccreditation materials prior to the expiration of the 3-month grace period, the laboratory will be required to complete the initial application and, upon completion of the initial application, the laboratory shall receive a new certificate number. If the lab director contacts the AANEM with extenuating circumstances, the AANEM will consider extending the grace period to 6-months or another reasonable time-frame that is acceptable to the committee.