cpt code for two stage acl reconstruction

The outputs are available to be used by all individual insurers and providers including CCSD and non-CCSD members. Osti L, Buda M, Osti R, Massari L, Maffulli N. Sports Med Arthrosc Rev. 0000006922 00000 n View matching HCPCS Level II codes and their definitions. 0000003281 00000 n 2022 May 8;34(1):24. doi: 10.1186/s43019-022-00153-3. I'm not sure if I'm coding this correctly, so I could really use some advice. Osseous malalignment in the coronal or sagittal planes would also need correction along with or prior to revision ACL surgery. To quantify healing of tibial bone tunnels after bone grafting in two-stage ACL reconstruction revision. Erickson BJ, Cvetanovich G, Waliullah K, Khair M, Smith P, Bach B Jr, Sherman S. Orthopedics. "This is an obvious frustration to surgeons and coders " she adds "because the range of work in a repair versus a reconstruction is wide." 0000014223 00000 n Avoid soaking the wound in water until it has thoroughly sealed and dried. You may need a walker, cane, or crutches for the first few days or weeks until you are comfortable enough to walk without assistance. 2023. 0000004102 00000 n Level of evidence: However modifier -22 should be used only if written documentation including an operative report intraopera-tive photos and a letter from the surgeon verify that the extra work was done. Patient expectations must be tempered because functional outcomes and return to pre-injury sports are inferior to a primary surgery. 2021 Oct 12;11(4):e20.00055. The stretched ligament shrinks to its normal size, thus returning stability to the knee. The risk of infection is slightly higher after revision surgery than after primary total knee replacement. Both can't be billed. Although both procedures have the same goalto relieve pain and improve functionrevision surgery is different than primary total knee replacement. doi: 10.1016/j.eats.2020.08.024. M23.611 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. 0000020113 00000 n 2019 Sep 18;31(1):10. doi: 10.1186/s43019-019-0010-6. Opioid dependency and overdose have become critical public health issues in the U.S. 0000103679 00000 n Etiological factors responsible for failure, Etiological factors responsible for failure of an anterior cruciate ligament failure ( RTS, Right knee arthroscopy, viewing from the anterolateral portal, knee in 90 flexion. Hybrid Bone-Grafting Technique for Staged Revision Anterior Cruciate Ligament Reconstruction. As the major stabilizing ligament of the knee, it prevents buckling and instability. As with every use of an unlisted procedure code documentation should include a thorough description of the procedure an operative note and a letter from the surgeon.". 0000017278 00000 n Of these, tunnel malposition and recurrent trauma are the most common causes. doi: 10.3928/01477447-20160324-01. Erickson BJ, Cvetanovich G, Waliullah K, Khair M, Smith P, Bach B Jr, Sherman S. Orthopedics. ACL problems are typically the result of pivoting, twisting, hyperflexion and hyperextension injuries to the knee. startxref There are different types of revision surgery. 0000030828 00000 n WebThe second stage of the double-stage ACL revision reconstruction is reconstructing the ACL with a new graft. 0000004907 00000 n View any code changes for 2023 as well as historical information on code creation and revision. After removing the original implant, your doctor will prepare the bone surfaces for the revision implant. The spectrum of ACL failure includes symptoms of recurrent instability, pain, and/or stiffness. WebIntrinsic failure of the graft can occur from graft impingement or trauma. (Left) In this tibial component, an additional block has been attached to make up for lost bone. Removing the implant leads to a higher chance of curing the infection, but is associated with a longer recovery. And arthro-scopic ACL repair or reconstruction has only one code: 29888 (Arthroscopically aided anterior cruciate ligament repair/augmentation or reconstruction). I think 27558 more appropriate. 0000017565 00000 n As with any surgical procedure, there are risks associated with revision total knee replacement. The surgeon uses the middle third of the patient's quadriceps tendon and a bone plug from the upper end of the kneecap, which produces a larger graft for taller and heavier patients. [BTB allograft for revision surgery of the anterior cruciate ligament - part 2]. Because of the already surgically altered operative field ACL revisions are more complex than repairs or reconstructions. Recent reports have noted a 2% traumatic rupture rate of autogenous ACL reconstruction and a 15% rupture rate for allograft. This is needed to make sure that you are healthy enough to have the surgery and complete the recovery process. When this occurs, your knee can become painful and swollen. 0000020747 00000 n (Left) In this x-ray, the primary knee replacement implant is unstable due to weakened bone. Repair of the ACL involves using sutures to anchor the torn ligament to its original point of attachment on the femur to set it back into its correct anatomic site. Many types of medicines are available to help manage pain, including opioids, nonsteroidal anti-inflammatory drugs (NSAIDs), and local anesthetics. In osteolysis, the bone around the implant deteriorates, making the implant loose or unstable. Practices do not receive any less reimbursement when they bill 29888 for a repair but they similarly do not receive additional reimbursement when they bill 29888 for a reconstruction. The scarcity of codes for the ACL repair reveals the reimbursement challenge. 0000018696 00000 n Complete pain relief and restoration of function is not always achievable, however, and some patients may still experience pain or knee stiffness following revision surgery. Before The implant may begin to lose its attachment to the bone. <<0442EB843D58CB429143788B7DE0A388>]/Prev 973684>> If an artificial joint becomes infected, it may become stiff and painful. 2011 Sep;39(9):1889-93. doi: 10.1177/0363546511406871. 2021 Jan 29;9(1):2325967120977834. doi: 10.1177/2325967120977834. It is important to use opioids only as directed by your doctor. 0000003488 00000 n 0000076075 00000 n What to Do If Your Orthopaedic Surgery Is Postponed. 0000008438 00000 n In this procedure, the provider reconstructs both the intraarticular and extraarticularligaments of the knee joint. Once the incision is made, the doctor will move the kneecap and tendons to the side to reveal your knee joint. Ten consecutive patients underwent autogenous bone grafting prior to ACL reconstruction revision (four females and six males, average age 28years). After you wake up, you will be taken to your hospital room. Over time, however, a knee replacement may fail for a variety of reasons. eCollection 2022 Mar. Arthrosc Tech. Multiple revision anterior cruciate ligament reconstruction: not the best but still good. Methods: Epub 2022 Sep 7. When the infection has been cleared, your doctor will perform a second surgery to remove the antibiotic spacer and insert a new prosthesis. sharing sensitive information, make sure youre on a federal A physical therapist will give you specific exercises to strengthen your leg and restore range of motion so that you may begin walking and resume other daily activities as soon as possible after surgery. Coders reporting ACL revisions encounter the same limitations as they do for reconstructions essentially one code to describe any arthroscopic ACL procedure. In order for a total knee replacement to function properly, an implant must remain firmly attached to the bone. Careers. Regardless of whether the physician has to graft tendon and remove the ACL stump or simply anchor the stretched ACL to the patella without need for grafting or removal of damaged tendon the code is the same. 0000103578 00000 n PMC Expected immediate post-operative ACL tunnel diameter should be around 10 mm regardless of graft selection. Two-Stage Revision Anterior Cruciate Ligament Reconstruction. Reproduced from Daines BK, Dennis DA: Management of Bone Defects in Revision Total Knee Arthroplasty. 27427 is ligamnet reconstruction extra articular = iliot CPT GUIDELINES indcates that when the physician cannot complete the procedure through the arthroscope, and an open procedure is performed, list the open procedure first, code the scope diagnostic, and Read a CPT Assistant article by subscribing to. With arthroscopic guidance, a thermal probe is inserted into the knee, where it heats the damaged ligament to shrink and tighten it. eCollection 2021 Jan. Abdel-Aziz A, Waly MR, Abdel-Aziz MA, Sherif MM, Elhaddad H, Mostafa Zaky Abdelrazek BH. 2. Reduced range of motion or stiffness in the knee, Infection in the wound or the new prosthesis, Blood clots in the legs, which may travel to the lungs (pulmonary embolism), Medical problems such as heart attack, lung complications, or stroke. Your surgeon will use a piece of tendon from another part of your knee or a tendon from a deceased donor. 0000000016 00000 n This information is provided as an educational service and is not intended to serve as medical advice. Because the amount of work with a thermal shrinkage is far less than that involved with arthroscopic ACL repair (there are no sutures and only one incision for the scope) experts agree that the unlisted arthroscopy code (29999 Unlisted procedure arthroscopy) is appropriate to submit for this claim. To determine whether you have an infection, your doctor may order blood tests. 0000005807 00000 n This replacement tissue is called a graft. Revision for infection can be done in one of two ways, depending on the type of bacteria, how long the infection has been present, the degree of infection, and patient preferences. Rarely, bone graft material may be used to help rebuild the knee. After surgery, you will feel some pain. eCollection 2020 Dec. Knee Surg Relat Res. A drain may be placed in your knee to collect any fluid or blood that may remain after surgery. To break up scar tissue, your doctor may perform manipulation under anesthesia. Instr Course Lect. When revisions include complexities like those listed above the coding option is to append modifier -22 (Unusual procedural services) to 29888. Each parameter significantly increased over time. Coding for arthroscopic reconstruction of anterior cruciate ligament (ACL) surgery. 0000103797 00000 n Extraarticular ligaments are the ligaments located outside the knee joint. Correct me if I am mistaken. However modifier -22 should be used only if written documentation including an operative report intraopera-tive photos and a letter from the surgeon verify that the extra work was done. 0000004674 00000 n An autograft is a graft of tissue from one point to another of the same individual's body. 09/12/2018 00:00:00 to 23/12/2018 00:00:00, This site uses cookies. 0000006521 00000 n 305 102 Please enable it to take advantage of the complete set of features! According to the American Academy of Orthopaedic Surgeons' (AAOS) Complete Global Service Data Guide, 29888 includes the following procedures: minor synovial resection for visualization (e.g., 29875) articular shaving, debridement, chondroplasty (e.g., 29877, 29879) notchplasty (debridement of the intercondylar notch of the femur) ACL stump removal (replacement of ligament) synovectomy and fat-pad resection (e.g., 29875, 29876) intra-articular ligament reconstruction (e.g., 27428, 27558) harvesting of graft (20924) diagnostic arthroscopy (29870) additional portals or enlarging portals internal fixation of graft. Rotator Cuff and Shoulder Conditioning Program. 0000005349 00000 n Your doctor and nurses will work to reduce your pain, which can help you recover from surgery faster. Instr Course Lect 2013; 62:341-348. An antibiotic spacer placed in the knee during the first stage of treatment for joint replacement infection. The surgeon should explain the specific complications he or she encountered (removal of graft material distant graft site etc.) Depending on your condition, you may need to stay at a nursing facility or rehabilitation center for some time after you leave the hospital. 0000003323 00000 n Revision ACL reconstruction can be performed in one or two stages. Sometimes, however, the knee remains stiff. This spacer is treated with antibiotics to fight the infection and will remain in your knee for several weeks. When it comes to ACL reconstruction surgery you have two main options, autograft and allograft. This immune response also attacks the healthy bone around the implant, leading to a condition called osteolysis. My predecessor coded [], Copyright 2023. When the tendon is harvested from the patient, harvesting takes place at the same time as the reconstructive surgery. 0 You will also work with your therapist to ensure that you can straighten your leg and then bend your knee to at least 90 degrees of flexion. 0000004790 00000 n "This is an obvious frustration to surgeons and coders " she adds "because the range of work in a repair versus a reconstruction is wide." One of the most serious complications facing patients who undergo revision surgery is infection. 8600 Rockville Pike Doing so indicates to the payer that extra work was performed above and beyond the normal scope of the procedure. And arthro-scopic ACL repair or reconstruction has only one code: 29888 (Arthroscopically aided anterior cruciate ligament repair/augmentation or reconstruction). Several codes describe open ACL repair and reconstruction, but with the advent and domination of arthroscopy, the codes are largely obsolete. During this time, you will also receive intravenous antibiotics. JOSPT 2012 305 0 obj <> endobj 0000007234 00000 n xref Detailed patient assessment, imaging, and studying details of the index surgery are critical prior to planning revision surgery. Although recovery after revision surgery is usually slower than recovery after primary total knee replacement, the type of care you will receive is very similar. 0000007124 00000 n Reproduced from Parvizi J, Azzam K: Periprosthetic fractures about the knee, American Academy of Orthopaedic Surgeons website: Orthopaedic Knowledge Online Journal, 2008. Removing this cement from the bone is a time-consuming process that adds to the complexity and length of the revision surgery. Before When the bone is shattered or weakened from osteoporosis, the damaged section of bone may need to be completely replaced with a larger revision component. The doctor then bends your knee in an attempt to break up the scar tissue. Knee Surg Sports Traumatol Arthrosc. 2021 Jan;37(1):195-205. doi: 10.1016/j.arthro.2020.08.031. In a 2-stage surgery, the implant is removed, the joint is washed out, and a temporary cement spacer is placed in your knee. Your doctor will examine the soft tissues in your knee to make sure that they are free from infection. To begin, your doctor will follow the line of the incision made during your primary total knee replacement. This is then followed by intravenous antibiotics. 2023 Jan;31(1):340-348. doi: 10.1007/s00167-022-07151-8. FOIA This percentage will help the payer to determine what extra percentage of the normal fee to reimburse for the extra work. Reconstruction of a torn ACL is significantly more involved and is accomplished through one of three methods, all of them arthroscopic: In all three methods, the new tendon is inserted through holes drilled in the tibia and femur, pulled through, and secured in position with bio-absorbable or metal screws. The .gov means its official. Methods: Ten consecutive patients underwent autogenous bone grafting prior to ACL reconstruction revision (four females and six males, average age 28years). NCI CPTC Antibody Characterization Program. The Danish registry recently published a report indicating that 3% of all ACL reconstructions were revised within the first 2 years. WebTwo-Stage Revision Anterior Cruciate Ligament Reconstruction: A Systematic Review of Bone Graft Options for Tunnel Augmentation 2020 Mar;48 (3):767-777. doi: Also, patients who are younger when they undergo the initial knee replacement may "outlive" the life expectancy of their artificial knee. International Perspective on Revision Anterior Cruciate Ligament Reconstruction: What Have We Been Missing? Trends in Primary Anatomical Single-Bundle Anterior Cruciate Ligament Reconstruction Practice in Adult Patients Prevalent Among Arthroscopy Surgeons of Six Southern States of India. Foot and ankle movement also is encouraged immediately following surgery to increase blood flow in your leg muscles to help prevent leg swelling and blood clots. In the case of allografts, a low level of immunologic reaction can weaken the graft and cause early failure as well. It is rare to do them "Open." An ACL injury can be relatively minor, such as a pull or stretch, or severe, where the ligament is partially torn or completely ruptured. Be aware that although opioids help relieve pain after surgery, they are a narcotic and can be addictive. Revision ACL reconstruction maybe performed as a one-stage or two-stage procedure. Your doctor will usually order imaging tests to learn more about the condition of your knee. As with every use of an unlisted procedure code documentation should include a thorough description of the procedure an operative note and a letter from the surgeon. 0000008179 00000 n %%EOF 0000009634 00000 n It may also feel stiff or unstable, making it difficult to perform your everyday activities. When revisions include complexities like those listed above the coding option is to append modifier -22 (Unusual procedural services) to 29888. The most common types of anesthesia are general anesthesia (you are put to sleep) or spinal, epidural, or regional nerve block anesthesia (you are awake but your body is numb from the waist down). 0000018169 00000 n Finally, your doctor will insert the specialized revision implant, repair any surrounding soft tissues that are damaged, and carefully test the motion of the joint. Please enable it to take advantage of the complete set of features! In either case, the implant was firmly fixed. 0000011499 00000 n 0000006205 00000 n ACL surgery is defined by CPT 29888 (Arthroscopically aided anterior cruciate ligament These coding principles set out how the authors intend that the codes and narratives within the CCSD Schedule are interpreted and used. Severe tunnel dilatation, infection, or arthrofibrosis necessitates a two-stage approach. If cement was used in the primary total knee replacement, this is removed, as well. 0000076190 00000 n 0000006682 00000 n Minor ACL injuries can be treated nonoperative-ly with physical therapy and bracing, and incomplete tears can be repaired without the use of graft material, whereas torn ACLs have to be reconstructed with the use of autograft or allograft tissue. As soon as your pain begins to improve, stop taking opioids. I think AAOS was meant, not AAQOS. Subscribe to. 15 Historically, the failure rate of 2017 Feb 15;66:543-556. He or she may recommend that you continue taking the blood-thinning and antibiotic medications that you started in the hospital. 0000008849 00000 n Federal government websites often end in .gov or .mil. This site needs JavaScript to work properly. Donor tendon, or allograft, is used to create the new ACL. The stitches or staples will be removed several weeks after surgery. official website and that any information you provide is encrypted 0000007709 00000 n Osteolysis (red arrow) has occurred around the tibial component, causing it to become loosened from the bone (blue arrow). The average ORs, URs and BMD at 24weeks after bone grafting were higher than those at 12weeks, which suggests that at 24weeks after bone grating, the condition of the patients' beds becomes favorable for safe implantation and fixation of ACL graft revision. 2023 Feb;31(2):559-571. doi: 10.1007/s00167-022-07197-8. Laboratory tests. Not only must the new graft become a part of your knee, a process called graft incorporation, but you need to restore normal muscle strength to ensure the knee is well protected. I've copied a piece of a C [QUOTE="Orthocoderpgu, post: 383507, member: 29238"]Does anyone know which ligaments are intra-articular & which are extra-articular? Arthroscopic ACL reconstruction is a much more involved procedure than arthroscopic ACL repair" " says Susan Callaway CPC CCS-P an independent coding consultant and educator based in North Augusta S.C "yet there is just one code to describe the procedure." 0000005015 00000 n The ACL is located in the center of the knee, behind the kneecap, and runs from the femur to the tibia. 0000103422 00000 n To plug inpatient facility revenue drains, subscribe to, Crosswalk to an anesthesia code and its base units, and calculate payments in a snap! In a primary total knee replacement, the surfaces of the femur, tibia, and patella are replaced with implants. There are three main sources of autograft: bone-tendon-bone (BTB) graft of the patellar tendon or a tendon graft from hamstring or quadricep tendon. For information:Questions and Answers for Patients Regarding Elective Surgery and COVID-19. Price: $7,931 CPT Code: 29888 Anterior cruciate ligament reconstruction ( ACL reconstruction) is a surgical tissue graft replacement of the anterior cruciate It is important to continue moving and exercising your knee when you are home. The average BMD was 510 and 571mg/cm(3) at 12 and 24weeks, respectively, with a significantly higher value at 24weeks. ACL problems are typically the result of pivoting, twisting, hyperflexion and hyperextension injuries to the knee. and estimate how much more difficult (e.g. Arthroscopic or open ACL repair, thermal ACL shrinkage, revisions, and ACL repair along with other knee procedures make for coding headaches and reduced reimbursements, but you can avoid both through thorough documentation and correct modifier use. 2017 Mar;25(1):19-29. doi: 10.1097/JSA.0000000000000140. Borchers JR, Kaeding CC, Pedroza AD, Huston LJ, Spindler KP, Wright RW; MOON Consortium and the MARS Group. Epub 2018 Dec 17. Keywords: Because the amount of work with a thermal shrinkage is far less than that involved with arthroscopic ACL repair (there are no sutures and only one incision for the scope) experts agree that the unlisted arthroscopy code (29999 Unlisted procedure arthroscopy) is appropriate to submit for this claim. 2017 Apr;33(4):819-827. doi: 10.1016/j.arthro.2016.10.007. You will be asked to schedule a complete physical examination with your primary care doctor several weeks before revision surgery. 0000006602 00000 n 0000005966 00000 n WebThis case required a two-stage approach: Stage 1 consisted of bone grafting, followed by second-stage repeat revision ACL reconstruction with patellar tendon autograft, lateral The majority of patients who have revision surgery experience favorable long-term outcomes, including relief from pain and increased stability and function. Unable to load your collection due to an error, Unable to load your delegates due to an error, Etiological factors responsible for failure of an anterior cruciate ligament failure (, Right knee arthroscopy, viewing from the anterolateral portal, knee in 90 flexion. Aim: 20 percent 30 percent) the procedure was as a result of this altered surgical field. 0000006842 00000 n This percentage will help the payer to determine what extra percentage of the normal fee to reimburse for the extra work. 20 percent 30 percent) the procedure was as a result of this altered surgical field. Clipboard, Search History, and several other advanced features are temporarily unavailable. The anesthesia team, with your input, will determine which type of anesthesia will be best for you. (Top): Examples of metal augments that can be added to implants to make up for lost bone. This website also contains material copyrighted by third parties. Bethesda, MD 20894, Web Policies 0000102999 00000 n Am J Sports Med. Careers. 0000013979 00000 n ACL revision surgeries occur when an initial repair or reconstruction fails or the patient reinjures his or her ACL. 0000104055 00000 n Even if the implant remains properly fixed to the bone, pain, swelling, and drainage from the infection usually make revision surgery necessary. Intra-articular findings in primary and revision anterior cruciate ligament reconstruction surgery: a comparison of the MOON and MARS study groups. If the ligaments around your knee become damaged or improperly balanced, your knee may become unstable. Doing so indicates to the payer that extra work was performed above and beyond the normal scope of the procedure. This spacer is treated with antibiotics to fight the infection and will remain in your knee for several weeks. Before surgery, you will be evaluated by a member of the anesthesia team. An official website of the United States government. Accessed May 2015. Total knee replacement is one of the most successful procedures in all of medicine. 0000034378 00000 n 2016 May 1;39(3):e456-64. Arthrosc Tech. All rights reserved. 2020 Dec 21;9(12):e1917-e1925. Infection has to be ruled out prior to planning any reconstructive surgical procedure. doi: 10.1016/j.eats.2022.05.014. In some cases, tiny particles that wear off the plastic spacer accumulate around the joint and are attacked by the body's immune system. Bone Incorporation of Silicate-Substituted Calcium Phosphate in 2-Stage Revision Anterior Cruciate Ligament Reconstruction: A Histologic and Radiographic Study. Injured ligaments can make the knee unstable. Donor tendon, or allograft, is used to create the new ACL. Register Online, Autograft anterior cruciate ligament reconstruction (including arthroscopic and meniscectomy), Excision of lesion of peripheral nerve (e.g. The incidence of anterior cruciate ligament reconstruction (ACLR) surgeries is increasing and so is the number of revision surgeries for a failed ACLR. That would help in choosing 27427, 27428 & 27429. Limited Coding Options Several codes describe open ACL repair and reconstruction, but with the advent and domination of arthroscopy, the codes are largely obsolete. He may also use a graft to reinforce the repair of the ligament. An emerging procedure, thermal ACL shrinkage, is used to stretch injuries of the ligament that do not require tendon graft. Unable to load your collection due to an error, Unable to load your delegates due to an error. Arthroscopic Bone Graft Technique for Two-Stage Revision Anterior Cruciate Ligament Reconstruction. FOIA 0000102737 00000 n official website and that any information you provide is encrypted Webdecides between a single-stage or a two-stage revision. 0000075493 00000 n 0000006762 00000 n In most cases, this procedure is successful in improving range of motion. Practices do not receive any less reimbursement when they bill 29888 for a repair but they similarly do not receive additional reimbursement when they bill 29888 for a reconstruction. WebAim: To quantify healing of tibial bone tunnels after bone grafting in two-stage ACL reconstruction revision. In some cases, only one implant or component of the prosthesis has to be revised. The graft may come from your own bone (autograft) or from a donor (allograft). WebThe quadriceps tendon autograft is often used for primary (initial) reconstruction as well as revision (repeat) reconstruction procedures. The incision may be longer than the original, however, to allow the old components to be removed. Epub 2012 Aug 2. von Recum J, Schwaab J, Guehring T, Grtzner PA, Schnetzke M. Arthroscopy. Arthroscopic or open ACL repair, thermal ACL shrinkage, revisions, and ACL repair along with other knee procedures make for coding headaches and reduced reimbursements, but you can avoid both through thorough documentation and correct modifier use. 0000009928 00000 n Follow your doctor's instructions carefully to reduce your risk of developing complications, including blood clots and infection, during the first several weeks of your recovery. 0000007280 00000 n 0000004557 00000 n Introduction: Repair of the ACL involves using sutures to anchor the torn ligament to its original point of attachment on the femur to set it back into its correct anatomic site. If this occurs, metal augments and platform blocks can be added to the main components to make up for the bony deficits. In determining the extent of the revision needed, your doctor will consider several factors, including the quality of the remaining bone, the type and location of the fracture, and whether the implant is loose. Results: Conflict of interestSachin Tapasvi and Anshu Shekhar declare that they have no conflict of interest. 0000068971 00000 n In some cases, there may be significant bone loss around the knee. The possible risks and complications of revision surgery include: Managing Pain With Medications After Orthopaedic Surgery. Two-stage revisions are rarely performed, but are particularly useful when addressing substantial tunnel-widening, active

cpt code for two stage acl reconstruction 2023