The ROOT Act’s Real Impact: Rebuilding qCDSM Readiness

In the July/August 2022 issue of Radiology Management, I addressed one of the most persistent operational challenges in diagnostic imaging: obtaining complete and detailed clinical information from ordering providers for every exam, for every patient. At the time, that challenge was framed against the Appropriate Use Criteria (AUC) program's indefinitely delayed penalty phase. A June 15 LINK article covered where AUC policy stands today: the original program is gone, the Radiology Outpatient Ordering Transmission (ROOT) Act is the leading legislative vehicle to revive it in a substantially reworked form, and its odds now hinge on whether it rides along with the broader physician payment reform package that Congress may take up after the midterms.

We won’t repeat that ground here. Instead, this article picks up where the legislative tracking leaves off and focuses on the operational issues that imaging leaders should actually be doing, and for whom the ROOT Act’s design creates real preparation work.

The ROOT Act Implications

As detailed in June, the ROOT Act creates little new work on the furnishing side. Including the ordering physician’s National Provider Identifier (NPI) on a claim is not something AUC introduced and not something the ROOT Act adds. It is a current, general Medicare billing requirement for diagnostic tests under 42 CFR 410.32, independent of AUC entirely. Consultation results would not affect coverage or reimbursement of the imaging service itself, and there is no immediate prior authorization exposure; the Centers for Medicare and Medicaid Services (CMS) would instead use qualified clinical decision support mechanism (qCDSM) data to identify low-compliant ordering professionals and report to Congress, with any further compliance mechanism, including prior authorization, requiring additional legislation.

That is genuinely good news for organizations whose only connection to an imaging order is furnishing the study. For a meaningful subset of AHRA members, however, the story does not end there, because plenty of imaging organizations are not purely on the furnishing side of that relationship.

The ROOT Act’s compliance architecture routes data from the qCDSM directly to CMS, which means the qCDSM has to exist, be correctly configured, be genuinely invoked at the point of order entry, and reliably transmit data. Who owns that responsibility depends entirely on where your organization sits relative to the ordering side of the relationship.

Different Organizations, Different Levels of Operational Lift

For a freestanding imaging center, Independent Diagnostic Testing Facility (IDTF), or a radiology group with no employment or platform relationship to the physicians ordering studies, the operational lift really is close to what the June article described: confirm your registration and claims workflows correctly capture and transmit the ordering professional’s NPI and otherwise wait to see what Congress does.

For a hospital-based imaging department, a health system, or an integrated delivery network where ordering physicians are employed, credentialed, or simply operate on the same enterprise electronic health record (EHR) platform, most commonly Epic, the potential impact is different. In that setting, the qCDSM lives inside a workflow your organization controls, builds, and maintains. Someone in your organization will need to select, reactivate, or make visible an approved qCDSM, build it into order entry so it is actually triggered rather than bypassed, validate that it is transmitting data correctly, and, practically speaking, keep an eye on how your own employed or affiliated ordering physicians are trending long before CMS gets around to publishing anything. Many organizations let their pre-2024 qCDSM licenses and EHR integrations lapse (or inactivated them) once the original AUC program was rescinded. If the ROOT Act advances, that infrastructure does not restart itself.

The Timeline Doesn’t Mean You Should Wait

It is worth being precise about timing here, because it cuts against a natural assumption. The ROOT Act does not create prior authorization exposure on its own; CMS would have until 2031 to report findings to Congress, and any further compliance mechanism would require separate legislation after that. It would be easy to read that timeline as license to wait. That would be a mistake for organizations on the ordering side of the relationship, for two reasons that have nothing to do with the penalty structure.

First, EHR build work does not move at legislative speed. Reactivating or building new qCDSM integration into an Epic instance, or any enterprise ordering workflow, competes for IT resources against every other build request in the queue. Waiting for a final rule or a statutory deadline to start that conversation means starting it years later than the organizations that begin now.

Second, and more directly connected to what this column has emphasized for years, a qCDSM is only as useful as the clinical information available to it at the point of order entry. A mechanism that is technically integrated but fed incomplete or vague clinical indications will produce unreliable appropriateness determinations regardless of how well it is built. That is not a new problem introduced by the ROOT Act. It is the same problem this publication addressed in 2022, now with a federal reporting mechanism sitting on top of it.

What Imaging Leaders Should Be Doing Do Now

Regardless of whether the ROOT Act moves in the lame-duck session, passes later, or stalls entirely, the following work holds up on its own merits.

Determine where your organization actually sits. If you furnish imaging without an employment or platform relationship to your ordering physicians, your preparation list is short: confirm NPI capture and transmission is clean in your registration and claims workflows and monitor the legislation. If your organization employs ordering physicians or shares an enterprise EHR with them, treat this as an IT and workflow governance project.

Inventory what remains of your pre-2024 AUC infrastructure. Confirm whether qCDSM contracts, vendor relationships, or EHR build were fully decommissioned or simply left dormant, since that materially changes how much rebuilding is required.

Open the conversation with EHR governance now. Given realistic build timelines, waiting for a statutory trigger may create avoidable delays.

Continue the root-cause work on clinical information completeness independent of federal timing. Segment by patient population, emergency department, outpatient, and inpatient, since the referring relationships and system issues differ meaningfully across each. Distinguish people problems from system problems before choosing an intervention, and continue to treat an ICD-10-CM code alone as insufficient on its own. The American Hospital Association's 2015 Coding Clinic guidance that a written clinical diagnosis is required to support code assignment remains accurate and directly relevant to what any CDSM will need to function correctly.¹

Establish visibility before CMS does. If your organization has any visibility into ordering-provider behavior today, whether through an employed medical group or a shared EHR, consider establishing internal tracking of AUC consultation and clinical information completeness now, on your own terms, rather than waiting for CMS to eventually publish a low-compliant designation you first learn about from the outside.

The legislative path for the ROOT Act is being tracked closely by the AHRA Regulatory Affairs Panel, and the news for pure furnishing providers is genuinely reassuring: a simplified NPI-based claims requirement, no coverage impact from consultation results, and no near-term prior authorization exposure.

For organizations that also touch the ordering side of the relationship, through employment, platform, or affiliation, the operational picture is more involved, and the lead time required to rebuild qCDSM integration into an enterprise ordering workflow argues for starting the internal conversation now rather than waiting to see how the vote comes out.

1. American Hospital Association Coding Clinic® for ICD-10-CM and ICD-10-PCS, 4th Quarter 2015.