The Value of Specific Special Questions on Case Lists Submitted for ABOS Certification

The American Board of Orthopaedic Surgery (ABOS) collects sequential Current Procedural Terminology (CPT)-coded surgical case lists from candidates for initial certification and from Diplomates participating in Maintenance of Certification. Because revisions or additions to the CPT system often take many years to reflect changes in surgical practice, in 2022, the ABOS began adding special questions for recorded cases in which the CPT codes alone do not identify potentially new or controversial surgical choices. In their article, Guyton et al. describe a unique opportunity to understand the practice patterns of both novice and seasoned orthopaedic surgeons. The described special-questions technique is entirely consistent with the guiding principles and values of the ABOS. At present, the ABOS case lists consist of CPT codes that are not current and thus do not adequately identify the safe, effective, and ethical practitioner1. These codes do not adequately define the range of the current state-of-the-art orthopaedic surgical practice. An important issue in utilizing CPT codes is that the accuracy of the list being submitted is based on a best-fit description. For a widely encompassing code such as CPT 23472, for total shoulder arthroplasty (TSA), the accuracy is high because the category is broad and all-encompassing. However, the specificity in identifying the type of TSA is low. This is where the drop-down questionnaire can allow for the clarification of the cementing technique or the use of reverse-component implantation. Considering how central the CPT codes are to orthopaedic practice, it is interesting to note that there are mechanisms to update CPT coding using CPT Category III, which enables updates for emerging technologies but is not being fully utilized. Engagement in this update process must begin with the American Medical Association (AMA) CPT Editorial Panel. The American Academy of Orthopaedic Surgeons (AAOS) representatives to the AMA may provide input and motivation to maintain a valid, up-to-date CPT list. In the era in which each item in an entire supermarket can be identified with a unique number, there is no valid reason why a TSA performed with cement or a reverse TSA cannot also be uniquely identified in a similar manner. One of the ABOS values is surgical innovation. However, during the development of an innovation and for a lengthy period thereafter, there is no established CPT code for it. If the innovation is sufficiently known, it can be identified and included in the certification process as a special question. Such practice differences that cannot be identified by CPT codes can be validly identified by audience participation polls. However, such differences can also be queried in a special-question drop-down list. The issue of whether to use the special questions is more about whether this technique is better at identifying a safe, effective, and ethical clinician than simply asking these questions verbally and in person. In essence, this study is about testing the test rather than testing the orthopaedic surgeon. The extensive reference list provided by Guyton et al. regarding orthopaedic techniques might include references on testing validity. This test has specific appeal in that the responses are recorded and can be compared between subgroups. The differences in practice patterns between novices and seasoned practitioners would be difficult to identify without a computerized response record. Having the drop-down questions included in the patient list provides the ABOS with an opportunity to perform a fair and homogeneous evaluation. From a practicing orthopaedic surgeon’s view, one would like to have a sense that the practice profile is within commonly accepted guidelines. The special questions allow for either assurance that the practice is mainstream or modifications to make the practice mainstream. This novel report would benefit from subsequent updates to monitor practice patterns. Descriptive studies of trends in the field have been previously published with the approval of the Research Committee of the ABOS. The additional data will be an extension of the previous publications and are too interesting to remain unstudied.