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Evidence-Based Reviews

Maintenance of certification and licensing: What you need to know

New system emphasizes self-assessment, performance improvement

Vol. 12, No. 02 / February 2013

Discuss this article at

In 2000, the American Board of Medical Specialties (ABMS) made a commitment to develop a maintenance of certification (MOC) system for their 24 specialty boards. MOC aims to keep physicians up to date because medical knowledge and practice are rapidly evolving and health care systems expect greater accountability linked with performance and outcomes. Previously, board certification for most specialties was limited to a 1-time board exam; upon passing, a clinician was considered board certified for life. The American Board of Psychiatry and Neurology (ABPN) first issued time-limited certificates for board certification in 1994; 2007 was the first year of initial MOC enrollment for ABPN. Diplomates whose certificates were issued before October 1, 1994 are not required to participate in the MOC program.

The ABPN time-limited certificates are on 10-year cycles and require diplomates to fulfill 4 MOC program components: Professional Standing, Self-Assessment and Continuing Medical Education (CME), Cognitive Expertise, and Performance in Practice (PIP) (Table).1 Requirement details are available at

The ABMS MOC initiative is closely aligned with other initiatives, such as maintenance of licensure (MOL), that will impact all physicians, including those who are not board certified and those who were certified before October 1, 1994 and therefore not required to participate in MOC. Licensure, reimbursement, and institutional credentials are developing required measures based on self-assessment and performance.


Maintenance of certification: 4 components



Professional Standing

Diplomates must hold an active and unrestricted license to practice medicine in ≥1 state commonwealth territory or possession of the United States or province of Canada

Self-Assessment and CME

Self-assessment: Diplomates must participate in ≥2 major broad-based self-assessment activities that must cover new knowledge and/or current best practices and provide feedback to the diplomate that can be used as the basis for focused CME lifelong learning and/or career development

CME activities: Diplomates are required to complete an average of 30 specialty or subspecialty Category 1 CME credits per year over the 10-year MOC cycle. At least an average of 8 of the CME credits per year (averaged over 2 to 5 years) should involve self-assessment

Cognitive Expertise

Diplomates must pass a cognitive examination before the expiration date of their certificates

Performance in Practice (PIP)

Diplomates will be required to complete 3 PIP units over the 10-year MOC cycle each consisting of both a clinical module (chart review) and a feedback module (patient/peer second-party external review)

CME: continuing medical education; MOC: maintenance of certification

Source: Adapted from reference 1

MOC requirements

The ABMS developed its MOC program around 6 general competencies identified by the Accreditation Council for Graduate Medical Education:

  • professionalism
  • patient care and procedural skills
  • medical knowledge
  • practice-based learning and improvement
  • interpersonal and communications skills
  • systems-based practice.

The ABPN implemented a 10-year MOC program for diplomates certified or recertified before 2012. Requirements for recertification are phased in over a period of time, depending on the diplomate’s most recent certification year.2 Diplomates certified in 2012 or later will be enrolled automatically in ABPN’s Continuous Pathway to Lifelong Learning Program, a web-based system that maintains progress records and helps direct diplomates to activities that meet the 4 MOC program components.1 Clinicians certified before 2012 may choose to participate in the program.

Physicians with “lifetime” certificates are not required to participate in MOC; there are no consequences for physicians who are not required to participate in MOC and choose not to participate, because MOC is a voluntary system. Physicians with time-limited certificates can choose not to participate, but would forfeit their certification. Physicians with certifications in multiple specialties may consider the value of maintaining all of their certifications because it would require them to participate in multiple MOC programs.

Two of the 4 parts of MOC (Parts I and III) are extensions of existing board certification requirements. Part I stipulates a diplomate hold a valid and unrestricted license in ≥1 states or jurisdictions in the United States, its territories, or Canada. Part III (Cognitive Expertise) requires that he or she must pass a cognitive examination every 10 years. To qualify to take the cognitive exam, a diplomate must meet all current MOC requirements.

Parts II and IV integrate continuing education, self-assessment, and the ability to apply both to practice improvements. Part II requires an average of 8 CME credit hours that include a self-assessment component; this likely would eliminate most traditional CME activities. The ABPN stipulates that feedback from the self-assessment must include a comparison with peers and specific literature recommendations for each question in the self-assessment. A small but growing number of accredited CME providers have developed self-directed CME activities that meet these criteria. As of 2014, only ABPN-approved self-assessment activities can be used to meet Part II requirements.

Part IV, the PIP activity, has raised the most concern. The PIP component focuses on quality improvement in 2 parts: a clinical module and a feedback module. This targets active clinicians, and both modules focus on quality improvement activities. The clinical module consists of a baseline chart review by the physician MOC applicant in which results are compared with best practices or practice guidelines. The practitioner-applicant repeats a second chart review after a period of time to determine if intervening practice improvements had a positive impact.

The feedback module consists of reviews of clinical performance by patients, peers, or other second parties such as other practice staff or administrators. These are repeated after a period of time to determine whether practice improvements have been effective.

The PIP model (assessment, practice improvement, reassessment) parallels requirements for Performance Improvement CME (PICME) activities. The American Medical Association (AMA) developed PICME at approximately the same time ABMS was creating MOC. PICME is aimed at changing physician behavior within the context of their clinical practice and is divided into 3 stages:

  • Stage A: learning from current practice performance assessment
  • Stage B: learning from the application of performance improvement to patient care
  • Stage C: learning from the evaluation of the PICME effort.

Clinicians can earn 5 AMA Physician’s Recognition Award (PRA) Category 1 Credits by completing each of the first 2 stages, and 10 additional credits by completing Stage C.3 Many accredited CME providers have developed PICME activities that meet the MOC Part IV criteria for ABPN. A list of available activities to meet ABPN Part IV of MOC can be found on the ABPN’s website (see Related Resources). Many of these activities also meet requirements for other specialty certifications and/or provide alternative CME credit (eg, American Academy of Family Physicians [AAFP] credit).

For example, a coalition of academic, nonprofit, and business organizations—the NOW Coalition for Bipolar Disorder— developed an online quality improvement activity (see Related Resources), which the ABPN certified for assessment and PIP points. It also is certified for 20 points toward the Self-Evaluation of Practice Performance MOC requirement through the American Board of Internal Medicine’s Approved Quality Improvement Pathway, 20 AMA PRA Category 1 Credits™, and 20 Prescribed Credits by the AAFP. Many physicians hold multiple board certificates, and this kind of activity can simultaneously meet requirements for licensure and several MOC programs.

Merging requirements

Although many ABPN diplomates are not subject to the MOC process because of “grandfather” provisions, the basic components of ABMS’ MOC are being integrated into relicensure, institutional credentials, and reimbursement models. In 2004, the Federation of State Medical Boards (FSMB) began work on a plan for MOL. This was in response to concerns about the current focus on CME credit as a measure of continuous professional development while recognizing that health care has intensified its focus on patient safety, measuring patient outcomes, and system-based health care delivery.4 The core components of MOL include:

  • reflective self-assessment
  • assessment of knowledge and skills
  • PIP.

The FSMB plan does not include a mandatory exam and does not require physicians to participate in MOC or Osteopathic Continuous Certification for DOs. However, because of the similarities between MOL and MOC, the FSMB recommends that state medical boards recognize physicians who are actively participating in an MOC program as essentially meeting the MOL requirements. The first group of state medical boards began testing MOL during summer 2012. Each state and territorial medical board will adopt its own version of MOL as it has with its current licensing requirements. Adopting MOL by all medical boards could take several years. However, there is no question that the principles behind MOC will become part of new state licensing requirements.

Effects on reimbursement

In 2012, the Centers for Medicare and Medicaid Services’ Physician Quality Reporting System MOC Program Incentive provided a 0.5% incentive payment to physicians participating in a qualified MOC program.5 Other insurers are examining similar reimbursement incentives tied to practice assessment and improvement. Public reporting of quality metrics also is becoming more prevalent in practice and reimbursement incentives.

Related Resources

  • Pinals DA. Ready or not, here it comes: maintenance of certification. J Am Acad Psychiatry Law. 2011;39(3):294-296.
  • American Board of Psychiatry and Neurology, Inc.
  • Maintenance of certification. American Board of Psychiatry and Neurology, Inc.
  • NOW coalition performance improvement (PI) CME activity. NOW Coalition for Bipolar Disorder.


Dr. Kues reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.


1. American Board of Psychiatry and Neurology. Inc. Maintenance of Certification (10YR-MOC). Accessed December 18, 2012.

2. American Board of Psychiatry and Neurology. Inc. Maintenance of certification (CP-MOC). Accessed December 18, 2012.

3. American Medical Association. The Physician’s Recognition Award and credit system. Published 2012. Accessed December 18 2012.

4. Federation of State Medical Boards. Maintenance of licensure (MOL) information center. Published 2012. Accessed December 18, 2012.

5. Centers for Medicare and Medicaid Services. Physician quality reporting system. Published September 27 2012. Accessed December 18, 2012.

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