The ROOT Act amends section 1834(q) of the Social Security Act to change how Medicare’s Appropriate Use Criteria (AUC) program collects and uses data. Beginning January 1, 2026, qualified clinical decision support mechanisms (CDSMs) must deliver specified data to the Secretary of HHS; furnishing providers must include the ordering professional’s NPI on claims; and CMS will calculate an ordering professional’s compliance rate and identify so‑called “low compliant” clinicians.
The bill also creates several explicit exemptions (small and rural practices, clinical trials, and certain screening tests) and requires CMS to adhere substantially to an existing specialty-society endorsement approach when specifying AUCs and CDSMs.
This is a technical but consequential rewrite of the AUC data pipeline. It shifts the program from a payor‑centric checkbox to a data‑driven monitoring regime that relies on vendor-supplied feeds and a single compliance metric to flag clinicians.
That creates new reporting obligations for CDSM vendors and operational changes for imaging facilities and ordering clinicians, and it gives CMS the authority to explore enforcement tools such as prior authorization or payment adjustments based on the five‑year study required by the statute.
At a Glance
What It Does
Mandates that qualified CDSMs transmit specified information to the Secretary starting January 1, 2026; requires the furnishing professional to place the ordering professional’s NPI on claims; defines a compliance rate for ordering professionals and directs CMS to identify low‑compliant clinicians. It also enumerates exemptions for certain services and practice settings and directs CMS to follow a specialty society endorsement model when adopting criteria.
Who It Affects
Qualified CDSM vendors (reporting burden and new data interfaces), imaging facilities and billing departments (must include ordering NPI), ordering professionals (subject to compliance measurement and potential downstream policy actions), and CMS (new data intake, analysis, and oversight responsibilities).
Why It Matters
The bill creates a concrete data stream from decision support tools to CMS that can be used to monitor and potentially discipline clinicians’ imaging orders; it reduces some administrative burden for small and rural practices via carve‑outs but increases compliance and technical demands on vendors, radiology groups, and billing systems.
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What This Bill Actually Does
The bill remodels the AUC program around data reporting. It requires CDSMs that clinicians consult when ordering Medicare‑covered advanced imaging to provide the Secretary with the underlying consultation data the tool generated, plus the additional fields CMS identifies by rule.
That means vendors can no longer treat the CDSM call as internal; they must support a reporting interface that transmits structured data to HHS on a schedule and in a format the agency specifies.
At the claims level, the furnishing professional must put the ordering professional’s national provider identifier on the claim for applicable imaging services. CMS will calculate a compliance rate for each ordering professional using CDSM data (the share of orders for which a CDSM was consulted, excluding listed exceptions) and annually designate those with rates below a CMS‑set threshold as “low compliant.” The bill replaces the older “outlier” terminology with this new label and directs CMS to use vendor‑reported data published on the agency’s qualified CDSM list when computing rates.The statute lists explicit exceptions: orders tied to clinical trials, orders from ordering professionals practicing in small practices (defined as 15 or fewer ordering professionals) or practices in rural Health Professional Shortage Areas, and a set of screening/preventive imaging services (mammography, lung CT screening, CT colonography, plus any other preventive imaging CMS designates).
CMS must also issue guidance or rules describing acceptable reporting approaches CDSMs can use to transmit their data to the agency.Finally, the bill compels CMS to study program results and the behavior of low‑compliant clinicians: the first analysis is due January 1, 2031, and repeats every five years. That study must analyze utilization impacts and propose remedial mechanisms—explicitly including prior authorization or fee schedule payment adjustments—if CMS concludes stronger corrective action is appropriate.
The provision requiring CMS to “substantially adhere” to the specialty society endorsement approach (per 42 C.F.R. 414.94 as of January 1, 2023) ties future AUC and CDSM specifications to an existing, society‑driven model for criteria development.
The Five Things You Need to Know
Effective date: most changes take effect January 1, 2026—qualified CDSMs must begin providing specified data to the Secretary from that date.
Claims requirement: the furnishing professional must include the ordering professional’s NPI on claims for applicable imaging services paid under Medicare.
Exemptions: orders for clinical trial participation, orders from ordering professionals in small practices (≤15 ordering professionals) or rural HPSA practices, mammography, lung‑CT screening, CT colonography, and other preventive imaging CMS designates are excluded from the compliance calculation.
Compliance metric: CMS will compute a compliance rate for each ordering professional equal to the percentage of orders where a qualified CDSM was provided, excluding exempted orders, and will annually label clinicians below a CMS‑set threshold as “low compliant.”, Study and remedies: CMS must produce a study by January 1, 2031 (and every five years) analyzing compliance and utilization and may recommend actions including prior authorization or targeted payment adjustments for low compliant clinicians.
Section-by-Section Breakdown
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Short title—Radiology Outpatient Ordering Transmission Act (ROOT Act)
Cabinet naming: a straightforward short title. This is the label that will appear in statutes and administrative references; it signals the bill’s focus on the transmission of ordering information and decision‑support outputs rather than on changing Medicare coverage or clinical standards directly.
CDSM reporting obligation to the Secretary
Adds a new subclause requiring CDSMs, beginning January 1, 2026, to provide the Secretary with the consultation outputs previously required for clinicians and the additional fields described elsewhere in the statute. Practically, CMS will need to specify what exact fields, formats, transmission cadence, and authentication methods vendors must support; vendors must build or modify interfaces to push data to CMS rather than simply returning results to the ordering clinician.
Operational changes: deadlines, exemptions, claim reporting, and vendor guidance
Updates the program date references to 2026 and replaces payment‑conditional language with a reporting‑centric model: instead of claims being accepted only if they include certain data, the law requires CDSMs to maintain and report consultation data to CMS. It adds the NPI requirement for furnishing professionals to include the ordering professional’s NPI on claims and enumerates specific exemptions (clinical trials, small practices, rural HPSA practices, and named screening tests). Finally, it directs CMS to publish guidance or rules on acceptable reporting methods for CDSMs, which sets up a rulemaking or guidance process defining technical and privacy safeguards.
Replacement of 'outlier' framework with an annual 'low compliant' designation and compliance rate methodology
Recasts CMS’s monitoring approach: CMS must determine an annual compliance rate for each ordering professional using CDSM data from tools listed on the agency’s qualified CDSM list and then designate clinicians with rates below an agency‑set threshold as 'low compliant.' The law defines compliance rate as the percentage of orders for which the clinician provided the CDSM consulted, and requires CMS to exclude the statute’s listed exceptions from the denominator. This locks a single, vendor‑fed metric into statute as the principal measure of clinician behavior under AUC.
Mandated study/report and specialty society endorsement requirement
Substitutes the older outlier study with a requirement that CMS study compliance and utilization and report to Congress by January 1, 2031, and every five years thereafter, and explicitly directs the study to evaluate and propose corrective mechanisms (e.g., prior authorization or fee schedule adjustments). Separately, the Secretary must 'substantially adhere' to the specialty society endorsement approach in 42 C.F.R. 414.94 (as of Jan 1, 2023) when specifying AUCs and CDSMs, which channels more influence toward specialty societies' processes for developing and endorsing criteria.
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Explore Healthcare in Codify Search →Who Benefits and Who Bears the Cost
Every bill creates winners and losers. Here's who stands to gain and who bears the cost.
Who Benefits
- CMS / HHS — gains structured, vendor‑supplied data feeds that permit longitudinal monitoring of ordering behavior and the ability to evaluate utilization trends and target corrective measures.
- Specialty societies — the statutory direction to 'substantially adhere' to the specialty society endorsement model strengthens their role in shaping which AUCs and CDSMs CMS recognizes.
- Small and rural ordering professionals — explicit carve‑outs for clinicians in small practices (≤15 ordering professionals) and those in rural HPSA practices reduce their exposure to the compliance metric and potential downstream enforcement actions.
- Patients concerned about overuse — if CMS uses the new data to curb inappropriate imaging through policy levers, patients may experience fewer unnecessary scans and associated harms.
Who Bears the Cost
- Qualified CDSM vendors — must develop secure, standardized reporting interfaces, maintain additional data records, and respond to CMS guidance or rulemaking; this creates engineering and compliance costs and may expose proprietary algorithm outputs.
- Furnishing professionals and billing departments — required to change claims systems to capture and transmit the ordering professional’s NPI on applicable imaging claims, adding operational and IT costs.
- Ordering professionals labeled 'low compliant' — face reputational risk and the prospect of CMS recommending remedial measures (prior authorization, payment adjustments) that could increase administrative burden and affect revenue.
- CMS operational units — will need resources to ingest, validate, analyze large vendor data feeds, conduct the mandated studies, and implement any consequential policies.
Key Issues
The Core Tension
The central dilemma is between transparency and oversight on one hand—collecting granular, vendor‑supplied CDSM data so CMS can detect and deter inappropriate imaging—and on the other hand protecting clinician workflow, vendor proprietary information, and small/rural providers from disproportionate technical and compliance burdens; the law privileges data‑driven monitoring but leaves unanswered how to balance those competing interests in rules and implementation.
The bill creates a high‑stakes data pipeline from vendor decision‑support tools into CMS. That raises immediate technical and governance questions that the statute does not fully resolve: what exact data elements will CMS require, how will CMS authenticate and secure vendor feeds, how will it validate data quality, and how will it reconcile discrepancies between vendor reports and claims data?
Vendors may resist or delay building interfaces if CMS requirements expose proprietary logic or impose disproportionate engineering costs.
The compliance rate, as defined, is an administrable single metric but imperfect: it measures whether a CDSM was 'provided' for an order, not whether the clinician followed the guidance or whether the guidance was clinically appropriate in a specific case. Exemptions for clinical trials, small practices, and certain screening tests blunt the program’s reach but also create opportunities for unintended gaps and for gaming (e.g., structuring practice arrangements to qualify for exemption).
The statute leaves crucial design choices to CMS—threshold levels, data formats, and enforcement mechanisms—and those choices will determine whether the approach improves care or simply shifts burden onto vendors and billing staff.
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