The Radiology Outpatient Ordering Transmission (ROOT) Act amends title XVIII of the Social Security Act to modify data collection requirements for appropriate use criteria (AUC) for applicable imaging services. Beginning January 1, 2026, the act expands the data that qualified clinical decision support (CDS) mechanisms must provide to the Secretary and retools reporting obligations for furnishing professionals.
It also introduces a new framework to measure ordering professional compliance, designates low-compliant practitioners, and requires a periodic study on utilization and potential adjustments to payment policies. The bill further requires Specialty Society Endorsement of AUC and CDS guidelines and preserves exemptions for certain imaging orders in specific contexts.
The effective date is straightforward: the amendments take effect in 2026.
At a Glance
What It Does
Starting in 2026, the mechanism for AUC data collection will require CDS to deliver to the Secretary the information described in prior subclauses and any additional data the Secretary deems appropriate. The furnishing professional must implement reporting and align with the updated data flows.
Who It Affects
Ordering professionals and their CDS providers, furnishing professionals (e.g., clinicians performing the imaging), and CMS/Medicare as the data steward. Small practices and rural providers will see specific exemptions, while CDS vendors will have new reporting responsibilities.
Why It Matters
It shifts imaging utilization oversight toward data-driven compliance, expands transparency in ordering decisions, and lays groundwork for potential payment adjustments linked to adherence to AUC reporting. The framework is designed to curb inappropriate imaging while maintaining access for beneficiaries.
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What This Bill Actually Does
The ROOT Act tightens Medicare’s approach to imaging through AUC data collection. By 2026, CDS systems used to guide imaging orders must report richer data to the Secretary, and the professionals who perform imaging must include the ordering clinician’s NPI on claims when applicable.
The legislation repurposes the term “furnishing professional” to reflect its relationship with CDS mechanisms and clarifies reporting obligations to support the Secretary’s implementation of the new data requirements. It also creates a formal category—low compliant ordering professionals—based on measured compliance rates, with potential consequences tied to future payment policy changes.
In addition, the Act requires a multi-year study on compliance and utilization and enshrines an endorsement process by specialty societies to ensure AUC guidelines remain aligned with federal standards. Several exemptions shield certain orders, including some preventive services and rural or small-practice contexts, from the full reporting regime.
Finally, the amendments take effect January 1, 2026, establishing a clear transition date for compliance. This structure aims to balance patient access with tighter controls on imaging appropriateness while enabling data-driven policymaking.
The Five Things You Need to Know
The Secretary will receive expanded data from qualified clinical decision support mechanisms starting January 1, 2026.
Furnishing professionals must include the ordering professional’s NPI on the claim for applicable imaging services.
A new category—low compliant ordering professionals—will be designated based on a defined compliance rate.
The Act requires a comprehensive study on compliance and utilization in 2031 and every five years thereafter, with potential policy options.
Specialty societies must endorse AUC approaches, aligning with CFR 414.94, and exemptions apply to certain imaging orders (e.g.
clinical trials, small rural practices, specific preventive services).
Section-by-Section Breakdown
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Expanded data reporting to the Secretary
The amendment adds a new subclause VIII to paragraph (3)(B)(ii) requiring, beginning January 1, 2026, that the mechanism provide to the Secretary the information described in subclauses III and IV, plus other information the Secretary may determine appropriate. This broadens the data set that informs AUC implementation and oversight.
Revised furnishing professional and CDS terminology
Subparagraphs (A)-(D) reorganize the language around the furnishing professional, renaming it to the “Qualified Clinical Decision Support Mechanism” and updating key dates. The changes shift the emphasis to data sharing through the CDS and to the Secretary’s reporting framework, rather than relying solely on traditional claim-based conditions.
Phased compliance timeline for imaging orders
Subparagraph (A) expands to require that beginning January 1, 2026, entities comply with the new reporting requirements as established by the Secretary, replacing the prior language that tied payment to a specific claim communication.
Furnishing professional reporting and CDS labeling
Subparagraph (B) changes labeling to “Qualified Clinical Decision Support Mechanism” and resets the timeline from 2017 to 2026. It also shifts the obligation to the mechanism to maintain and report information to support the Secretary’s rulemaking for later subsections (5) and (6).
New exemptions and subparagraphs (iv)-(vi)
Adds exempted categories: (iv) clinical trials, (v) small and rural practices, and (vi) specified exemptions for certain imaging services (e.g., certain preventive or screening imaging). The Secretary may determine additional exemptions, expanding relief from the full data-collection regime in defined contexts.
Other payment system considerations
Subparagraph (D) adds a catch-all: the Secretary may designate additional payment systems or mechanisms appropriate for implementing the data-collection and reporting regime established in this title.
Furnishing professional requirement—NPI on claims
Beginning January 1, 2026, the furnishing professional must include the national provider identifier (NPI) of the ordering professional on the claim for the service when the ordering professional differs from the furnishing professional.
Reporting guidance
The Secretary will issue guidance or rulemaking on how qualified CDS mechanisms report information collected to support the Secretary’s implementation of paragraphs (5) and (6).
Low compliant ordering professionals
Renamed from “outlier” to “low compliant ordering professionals,” this section requires annual determination of the total number of such professionals and defines the compliance rate used to designate someone as low compliant. The rate is based on the share of orders where a CDS mechanism was consulted and excludes exempt orders. The designation is tied to future policy actions under the Secretary’s purview.
Study and report on compliance and utilization
Not later than January 1, 2031, and every five years thereafter, the Secretary must study the compliance rates and their effect on utilization of applicable imaging services. The report must discuss potential mechanisms to improve compliance, including prior authorization and payment adjustments, and propose alternative thresholds for low-compliant ordering professionals.
Specialty society endorsement
Requires that the set of applicable AUC criteria and CDS mechanisms substantially adhere to the approach described in 42 CFR 414.94, aligning federal standards with professional society endorsement to ensure practicality and legitimacy of the AUC framework.
Effective date
The amendments take effect January 1, 2026, establishing a clear transition point for the new data collection, reporting, and compliance framework.
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Who Benefits
- Ordering professionals who maintain high CDS compliance will avoid designation as low compliant and may benefit from clearer feedback loops and potential alignment with payment adjustments.
- Qualified clinical decision support mechanism vendors gain a formal role in data collection and reporting, reinforcing demand for compliant CDS tools.
- Medicare beneficiaries may see improvements in imaging appropriateness and avoidance of unnecessary exposure and costs due to more consistent use of AUC.
- Small and rural practices gain targeted exemptions that lessen regulatory burden where workflow constraints or access issues are most acute.
- Specialty societies that endorse AUC guidelines will shape the standards used by clinicians and CDS tools, improving the legitimacy and interoperability of the framework.
Who Bears the Cost
- Low compliant ordering professionals may face increased scrutiny and potential payment policy consequences tied to compliance rates.
- Furnishing professionals and clinics must implement and maintain CDS reporting workflows, creating additional administrative obligations.
- Qualified CDS vendors must support data reporting requirements and integration with CMS systems, adding implementation costs.
- CMS will bear ongoing costs to administer guidance, monitor compliance, and update policy as data flows scale.
- Some imaging providers and payers may face changes in utilization management that could affect cash flow and claim processing.
Key Issues
The Core Tension
The central dilemma is balancing stronger oversight and data-driven incentives to reduce inappropriate imaging with the risk of added administrative burden and potential access barriers for some patients and providers.
The ROOT Act creates a data-driven framework intended to improve imaging appropriateness, but it also raises concerns about administrative burden, potential underuse, and the risk of gaming or misreporting to meet compliance metrics. The exemptions for clinical trials, small and rural practices, and certain preventive imaging services mitigate some burden but could dilute the data needed to drive systemic improvements.
The reliance on a compliance-rate metric hinges on robust, high-quality CDS data; if data quality is uneven or CDS tools lag in adoption, the intended effects may be uneven across provider types and geographies. Finally, the emphasis on Specialty Society Endorsement helps ensure professional legitimacy, but the integration of federal standards with diverse clinical practices will require careful calibration to avoid friction in real-world workflows.
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