Our GynOnc surgeon recently used the DaVinci to resect a recurrent cancer from the vagina cuff. I am at a loss as to how to code this one. Generally we use the closest open code with a 52 modifier. However in this case there were also extensive adhesions which required over 30 minutes of dissection. The mass was tracking into the upper perivaginal tissue which required radical resection, essentially a radical upper vaginectomy. He had to approach this via the pelivc sidewall & the peritoneum was adherred to the site of her previous lymph node dissection. Additionally it was difficult to develop the pelvic spaces due to previous surgery and took long than normal to mobilize the bladder. After this he was able to divide the paravaginal tissue and vaginotomy was made the upper right corner of the vagina was removed. He does notes this was a very extensive difficult dissection & took 2-1/2 hours to perform. He also took an omentum biopsy.

My dilemma is how do I bill with a 52 modifier for the laparoscope/robot and a 22 for the additional work and time?

Any ideas?