- RRT-ACCS is the NBRC's Adult Critical Care Specialty credential, requiring an active RRT for at least one year first.
- The exam has 170 multiple-choice questions (150 scored, 20 unscored) in 240 minutes, delivered via PSI.
- Two domains: RESPIRATORY CRITICAL CARE (80 scored items) and GENERAL CRITICAL CARE (70 scored items).
- New applicants pay USD 300 (USD 260 with the AARC member discount); reapplicants pay USD 250.
What RRT-ACCS Actually Is
RRT-ACCS stands for Registered Respiratory Therapist - Adult Critical Care Specialty. It is a specialty credential awarded by the National Board for Respiratory Care (NBRC) to respiratory therapists who demonstrate advanced knowledge and clinical judgment in managing critically ill adult patients. It is not an entry-level license and it is not a substitute for the RRT credential - it sits on top of it, signaling that a therapist has moved beyond general practice into the specific demands of intensive care.
If you're still sorting out the terminology, our companion pieces on what RRT-ACCS is and what the letters mean cover the basics in more depth. This article focuses on what the certification involves mechanically: who administers it, what the exam looks like, what it costs, and what it takes to keep it.
Who Governs the Credential
The National Board for Respiratory Care develops the content, sets eligibility rules, and determines the passing standard for the ACCS examination. PSI is the third-party testing provider that administers the exam at physical test centers. This separation matters practically: your application and eligibility questions go through the NBRC's process, while your scheduling, testing-day logistics, and in-center rules are governed by PSI.
Testing-center delivery is closed book. Candidates get access to an on-screen calculator built into the exam software, but personal calculators are not permitted, and scheduled breaks do not stop the exam clock. That last detail catches people off guard - if you take a break, the 240-minute timer keeps running.
Who Can Apply
Eligibility for the ACCS exam is narrower than it looks at first glance. Candidates must already hold the RRT credential, and they must have held it for at least one year before applying. There is no separate "entry-level" version of this exam - it assumes you're already a fully credentialed respiratory therapist with a year of standing behind you.
For a full breakdown of prerequisites, application steps, and how the one-year clock is counted, see our dedicated RRT-ACCS requirements guide. It's worth reading before you pay any fees, since eligibility mistakes are the easiest way to waste an application cycle.
Exam Format and Question Style
The ACCS exam consists of 170 multiple-choice questions, broken down into 150 scored items and 20 unscored pretest items. You won't know which questions are which while you're testing, so every item should be treated as if it counts. Candidates get 240 minutes to complete the exam.
Forms are assembled using linear-on-the-fly testing, meaning each candidate receives a unique set of questions pulled algorithmically to match the blueprint's specifications, rather than everyone sitting a fixed, identical form. Two candidates in adjoining seats may see almost entirely different questions while still being tested on the same proportions of content.
The question style leans heavily on scenario-based clinical reasoning rather than simple recall. Expect multi-sentence patient vignettes - ventilator settings, hemodynamic numbers, lab values, a changing clinical picture - followed by a question asking what you'd do next or how you'd interpret the data. This is very different from memorization-style exams, and it's a major reason people ask how hard the RRT-ACCS exam really is.
Key Takeaway
Because 20 of the 170 questions are unscored pretest items with no way to identify them, pacing strategy should assume all 170 matter equally during the test.
The Two Content Domains
Under the Detailed Content Outline effective August 2026, the ACCS exam is built around two domains, and they are not weighted equally.
Domain 1: Respiratory Critical Care
This is the larger domain, contributing 80 of the 150 scored items. It centers on the respiratory-specific management of critically ill adults - advanced ventilator strategies, oxygenation and ventilation troubleshooting, airway management in complex cases, and interpretation of respiratory-focused diagnostic data.
- Mechanical ventilation modes and adjustments in unstable patients
- Advanced airway and oxygenation management
- Interpretation of blood gases and respiratory mechanics in the ICU context
Domain 2: General Critical Care
This domain contributes 70 scored items. It broadens out beyond the lungs into the full physiologic picture of the critically ill adult - hemodynamics, sedation, multi-system organ dysfunction, and the interdisciplinary decision-making that defines ICU practice.
- Hemodynamic monitoring and shock management
- Sedation, analgesia, and neurologic status in the ICU
- Multi-system complications and interdisciplinary care coordination
Because Respiratory Critical Care carries more scored items than General Critical Care, it deserves proportionally more study time - but not so much that General Critical Care gets neglected, since 70 items is still nearly half the scored exam. For a deeper walkthrough of both domains and their subtopics, our RRT-ACCS exam domains guide goes item by item.
| Domain | Scored Items | Relative Weight |
|---|---|---|
| Respiratory Critical Care | 80 | Larger domain |
| General Critical Care | 70 | Smaller domain |
Registration and Fees
New applicants pay a USD 300 examination fee. Reapplicants - candidates retesting after a prior attempt - pay USD 250. Eligible AARC members receive a one-time USD 40 discount on their first application, which brings that initial fee down to USD 260 when it's redeemed correctly through the AARC application link rather than applied after the fact.
These are application-level fees, separate from any prep materials, membership dues, or travel to a PSI test center. If you want the complete cost picture - including how the CE maintenance route factors into long-term spending - see our RRT-ACCS certification cost breakdown.
How Scoring Works
The ACCS exam uses raw-score comparison against an NBRC-determined cut score to decide who passes. There's no fixed percentage-correct threshold published as "the" passing score - the cut score is set by the NBRC and your raw performance on the 150 scored items is measured against it. For a full explanation of how this cut score is derived and what it means for how many questions you can afford to miss, read our RRT-ACCS passing score guide.
NBRC has published 2025 pass rates of 57% for new candidates and 34% for repeat candidates. These figures precede the August 2026 blueprint update, so they should be read as historical context rather than a guaranteed future outcome. Our RRT-ACCS pass rate analysis unpacks what these numbers do and don't tell you about your own odds.
Candidates get two initial attempts without any mandatory waiting period between them. After that, any subsequent attempt requires waiting at least 180 days before retesting. That gap makes a rushed, unprepared retake a costly decision - both financially and in lost momentum.
Who Actually Pursues This Credential
RRT-ACCS is pursued almost exclusively by respiratory therapists already working in or aiming for intensive care environments: medical ICUs, surgical ICUs, cardiac ICUs, and trauma centers where ventilator management and hemodynamic complexity are daily realities. Hospitals with dedicated critical care respiratory teams, academic medical centers running advanced ICU protocols, and transport or rapid-response programs are common employers looking for this credential specifically.
Because the credential requires an existing RRT and a year of practice, it functions as a career inflection point rather than a starting credential - therapists typically pursue it once they're already working adjacent to critical care and want formal recognition of that specialization, or want to be more competitive for ICU-focused openings. If you're weighing whether the investment translates into better roles or pay, our RRT-ACCS salary guide and ROI analysis dig into that question directly, and our RRT-ACCS jobs overview looks at the kinds of postings that reference the credential.
Keeping the Credential Active
RRT-ACCS is valid for five years, after which it must be renewed through the NBRC's Credential Maintenance Program. There are three accepted routes:
- Assessments and/or accepted CE: credential holders earn 0, 15, or 30 CE credits depending on assessment performance during the cycle. The CE route runs USD 25 annually, totaling USD 125 across the five-year cycle.
- Passing the applicable highest-level examination in the final year of the cycle.
- Earning another NBRC credential during the cycle.
None of these routes require starting from zero - the maintenance program is designed around ongoing professional engagement rather than a full re-examination by default. Still, it's worth planning your five-year cycle early rather than discovering the renewal window has crept up on you.
Mapping Your Study Time to the Blueprint
Generic study techniques only help if they're pointed at the right targets. Given that Respiratory Critical Care carries more scored items than General Critical Care, a simple and defensible approach is to open your prep cycle with ventilator management, oxygenation strategy, and airway topics, then move into hemodynamics, sedation, and multi-system complications once the larger domain feels solid - circling back to both domains in mixed review sessions as your exam date approaches.
Respiratory Critical Care Foundations
- Advanced ventilator modes and troubleshooting
- Blood gas and respiratory mechanics interpretation
- Complex airway management scenarios
General Critical Care Foundations
- Hemodynamic monitoring and shock states
- Sedation and neurologic assessment
- Multi-system organ dysfunction patterns
Integrated Scenario Practice
- Mixed-domain vignette questions under timed conditions
- Weak-area review across both domains
- Full-length timed practice runs
For a structured week-by-week plan built specifically around this blueprint, our RRT-ACCS study guide lays out a fuller schedule, and running scenario-style questions on our practice test platform is one of the most direct ways to get comfortable with the exam's vignette-driven question style before test day. Reviewing condensed content on our RRT-ACCS cheat sheet can also help during final review, and if your test date isn't locked in yet, check current RRT-ACCS exam dates and scheduling windows before building your timeline backward from it.
Frequently Asked Questions
Yes. You must hold the RRT credential and have held it for at least one year before applying for the ACCS exam.
The exam has 170 multiple-choice questions - 150 scored and 20 unscored pretest items - and candidates are given 240 minutes to complete it.
New applicants pay USD 300, and reapplicants pay USD 250. Eligible AARC members can get a one-time USD 40 discount on their first application, bringing that fee to USD 260.
You're allowed two initial attempts with no mandatory waiting period between them. Beyond that, any further attempt requires waiting at least 180 days.
It's valid for five years, after which it must be renewed through the NBRC's Credential Maintenance Program using assessments/accepted CE, a qualifying exam in the final year, or another NBRC credential.