ROOT Act
The Radiology Outpatient Ordering Transmission Act (ROOT Act) would overhaul Medicare data collection related to appropriate use criteria (AUC) for imaging services and expand the role of qualified clinical decision support mechanisms (QCDSM). Starting January 1, 2026, the bill shifts from requiring a clinician’s certification about AUC to requiring imaging “mechanisms” (QCDSM) to transmit specific information to the Secretary of Health and Human Services. It also creates new compliance metrics for ordering professionals, designates certain exceptions (e.g., clinical trials, small/rural practices, and certain preventive imaging), requires the ordering clinician’s NPI on claims, and gives CMS authority to implement potential payment or utilization controls for low-compliance ordering professionals. The act also directs ongoing study and reporting and seeks to align AUC implementation with specialty society endorsement standards. In short, the ROOT Act would significantly broaden data reporting from QCDSMs, introduce a measurable compliance framework for ordering clinicians, and potentially deploy enforcement tools (like prior authorization or payment adjustments) to improve the appropriateness and transparency of outpatient imaging orders beginning in 2026.
Key Points
- 1Data collection and transmission to CMS via QCDSMs starting 2026
- 2- Beginning January 1, 2026, the mechanism must provide to the Secretary information described in related subclauses and the relevant reporting paragraph, plus other information the Secretary determines appropriate and the form the Secretary specifies.
- 3- QCDSMs must report information to support the Secretary’s implementation of compliance and data requirements.
- 4Replacement of the old “furnishing professional certification” with a broader reporting framework
- 5- The requirement that the ordering professional certify or document certain information is replaced with a system where the QCDSM (and related data) must be transmitted to the Secretary, and the furnishing professional must meet the new reporting and data requirements.
- 6- The furnishing professional must meet the “furnishing professional” requirement including new data/reporting obligations beginning 2026.
- 7New exemptions and special categories
- 8- Clinical trials: imaging ordered in the context of a clinical trial is exempt.
- 9- Small and rural practices: orders from small practices (15 or fewer ordering professionals) or practices in Health Professional Shortage Areas in rural areas are exempt from certain requirements.
- 10- Specified exemptions for preventive or screening imaging: mammography, CT-based lung cancer screening, CT colonography, and other preventive/screening imaging as the Secretary determines appropriate.
- 11- The Secretary can designate other payment systems and appropriate exemptions.
- 12Compliance measurement and designation of “low compliant” ordering professionals
- 13- Starting 2026, the Secretary will annually determine how many ordering professionals are designated as “low compliant.”
- 14- A low-compliant designation is based on a compliance rate (a ratio of orders where QCDSM was consulted to total orders) for a specified period, with certain orders excluded.
- 15- Compliance data must come from QCDSMs published in the Secretary’s list and consulted by the ordering professional.
- 16Consequences and potential enforcement tools
- 17- The Secretary can use factors like prior authorization, payment adjustments under the Medicare physician fee schedule, or other mechanisms to improve compliance.
- 18- The bill contemplates data-driven approaches to reduce inappropriate imaging and may adjust payments or utilization for low-compliant providers.
- 19Specialty society endorsement and standard alignment
- 20- When specifying applicable AUC and QCDSMs, the Secretary must substantially adhere to the approach described in a listed CFR provision (42 CFR 414.94) as of January 1, 2023.
- 21Ongoing study and reporting
- 22- Not later than January 1, 2031, and every five years thereafter, the Secretary must study compliance rates and utilization, report on impacts, and propose adjustments (including alternative thresholds and other mechanisms to improve compliance).