FILED
`11/7/2022 12:31 PM
`FELICIA PITRE
`DISTRICT CLERK
`DALLAS CO., TEXAS
`Madison McCarrier DEPUTY
`
`CAUSE NO. DC-22-01593
`
`IN THE DISTRICT COURT
`
`160™ JUDICIAL DISTRICT
`
`DALLAS COUNTY, TEXAS
`
`§
`§
`
`§ §
`
`§§
`
`§
`
`§ §
`
`§
`
`JAMILAH SHABAZZ,
`
`Plaintiff,
`
`VS.
`
`JA TRUCKING,LLC and
`JERRY LEWIS ANDERSON,
`
`Defendants.
`
`NOTICE OF FILING OF CONTROVERTING AFFIDAVIT
`OF MARK LERNER, CFE, CPMA, QMC, ICD-10 PROFICIENT
`
`TO THE HONORABLE JUDGE OF SAID COURT:
`
`Pursuant to §18.001 of the Texas Civil Practice and Remedies Code, please take notice that
`
`Defendants JA Trucking, LLC and Jerry Lewis Anderson in the above-entitled and numbered
`
`cause, is filing the Controverting Affidavit of MARK LERNER, CFE, CPMA, QMC,ICD-10
`
`PROFICIENT,regarding Plaintiff, Jamilah Shabazz, a copy of which is attached hereto to be
`
`introducedat the trial of this cause.
`
`Respectfully submitted,
`
`DAVID ALLEN LAW Group, PLLC
`
`/s/ David G, Allen
`David G. Allen
`State Bar No. 00786972
`
`12222 Merit Drive, Suite 1200
`Dallas, Texas 75251
`(214) 748-5000 Telephone
`(214) 748-1421 Facsimile
`allen@dallenlg.com
`
`ATTORNEYSFOR DEFENDANTS
`JA TRUCKING, LLC AND JERRY LEWIS
`ANDERSON
`
`NOTICE OF FILING OF CONTROVERTING AFFIDAVIT
`OF MARK LERNER, CFE, CPMA, QMC, ICD-10 PROFICIENT—
`
`Page 1
`
`

`

`CERTIFICATE OF SERVICE
`
`I hereby certify that a true and correct copy of the foregoing Discovery has been
`
`served on counsel of record pursuant to the Texas Rules of Civil Procedure on November7,
`
`2022..
`
`#695852
`
`
`/s/ David G. Allen
`David G. Allen
`
`NOTICE OF FILING OF CONTROVERTING AFFIDAVIT
`OF MARK LERNER, CFE, CPMA, QMC, ICD-10 PROFICIENT —
`
`Page 2
`
`

`

`CAUSE NO.: DC-22-01593
`
`IN THE DISTRICT COURT OF
`
`DALLAS COUNTY TEXAS
`
`160™ JUDICIAL DISTRICT
`
`§
`
`§ § § § § §
`
`§
`
`§ § § § §
`
`§
`§
`§
`
`JAMILAH SHANI-AMINAH SHABAZZ,
`Plaintiff,
`
`vs.
`
`JA TRUCKING, LLC., AND
`JERRY LEWIS ANDERSON,
`Defendants.
`
`COUNTER-AFFIDAVIT REGARDING
`REASONABLENESS OF MEDICAL CHARGES
`
`STATE OF TEXAS
`
`COUNTY OF DALLAS
`
`LRLA)LP
`
`My nameis Mark Lerner, CFE, CPMA, QMC. I am fully competentto testify hereto based upon
`the following:
`
`I am qualified to make and submit this report based on my knowledge,skill, experience, training,
`and education in the field of medical fees, auditing, billing, and coding andto testify in support ofall or
`part of any of the matters contained herein. I have been in the healthcare field since 2000. I received my
`CPMA (Certified Professional Medical Auditor) certification in 2014, a qualification held by
`approximately 7% of the over 200,000 professional coders through the American Academy of
`Professional Coders (AAPC), the largest professional coding organization that is nationally recognized.I
`was awarded my CMCS (Certified Medical Coding Specialist) certification in 2015 through PAHCS
`(Professional Association of Healthcare Coding Specialist), and my QMC (Qualified Medical Coder) in
`2018.
`
`Additionally, Iam ICD-10 proficient having passed the required testing per AAPC. Furthermore,
`Iam a memberof the Association of Certified Fraud Examiners (ACFE)and am credentialed as a Certified
`Fraud Examiner (CFE). Lastly, as a member of the AAPC, I am pursuing my Certified Professional
`Compliance Officer (CPCO) and Certified Anesthesia and Pain Management Coder (CANPC)credentials,
`and a current member of the National Health Care Anti-Fraud Association (NHCAA). I have authored
`
`
`COUNTER-AFFIDAVIT REGARDING REASONABLENESS OF MEDICAL CHARGES
`Prepared by: Mark Lerner, CFE, CPMA, QMC, ICD-10 Proficient
`Cause No.: DC-22:01593 Jamilah Shabazz vs. JA Trucking, LLC and Jerry Lewis Anderson
`
`
`
`

`

`in-house
`two books in the allied health field, and provided medical coding audits and seminars,
`consultations, medical coding, medical billing, and retroactive billing nationwide since 2000. I previously
`wasthe lead coding expert for a Hawaii Attorney General’s Office case.
`
`My Curriculum Vitae providing additional details regarding my qualifications and professional
`experience is attached hereto as “Exhibit A” and adopted and incorporated herein by reference. I have
`provided testimony via deposition, reports, affidavits, and counter/controverting-affidavits for both the
`Plaintiff's and Defendant’s side, and to date have worked on more than 500 cases regarding medical
`coding, billing, fraud and abuse matters, and usual customary and reasonable charges. Furthermore, I
`have/or currently provided consultation services on auditing and compliance matters. My background and
`experiences include more than 35 years of auditing and collection management. I have provided seminars
`and audits to/for physicians, office personal, and the Department of Defense plus provided proactive and
`retro-active billing services, including the re-coding and re-filing of claims, as necessary. I have provided
`work products for attorneys,
`insurance companies, clinics, and physicians, providing analytical
`information for court cases. My client base has ranged from Wyoming to Texas, and Florida to Hawaii.
`
`By my experience, qualifications and training, as outlined above, including but not limited to my
`knowledge and experience analyzing and auditing medical charges and associated medical and billing
`records in more than 5000 other Texas lawsuits which included issues regarding the reasonableness of
`charges for medical care and myreliance on (use) of industry resources recognized as authoritative, as
`outlined below, regarding pricing of medical care in the State of Texas and the samelocalities where Ms.
`Jamilah Shani-Aminah Shabazz obtained the medical care for which he seeks compensation in this
`lawsuit, | am familiar with the usual, customary, and reasonable charges for medical services and
`procedures including, but not limited to both outpatient and inpatient office visits, surgical procedures,
`occupational and physical therapy, chiropractic care, laboratory and other testing, pharmaceuticals, and
`durable medical equipment for the care and treatment of patients such as Ms. Jamilah Shani-Aminah
`Shabazz. Other Texas lawsuits [ have worked on have included motor vehicle accidents (MVA), motor
`vehicle collisions (MVC), work related accidents, and slip and fall matters.
`
`As additional confirmation of my qualifications to provide testimony based upon current
`credentials and experiences, I possess more than 20 years in the field of healthcare, including but not
`limited to audits, billing, coding, consultations, retroactive billing, seminars, and training. I also refer to a
`Texas Supreme Court ruling (NO. 20-0071) which confirmed that an individual certified as a coder and
`medical auditor with a demonstrated knowledge of the CPT coding system does qualify the individual as
`an expert with regards to understanding medical documentation and medical billing practices.
`
`1. DOCUMENTS PROVIDED
`Asof the date of this report, I have received medical and/or billing records concerning the care and
`treatment provided Ms. Jamilah Shani-Aminah Shabazz including, but not limited to:
`
`PETITION(7 pages)
`Photos (8 pages)
`Pltf's Meds & Affs (768 pages)
`POLICEREPORT(10 pages)
`Video from DART (1 page)
`
`
`
`COUNTER-AFFIDAVIT REGARDING REASONABLENESS OF MEDICAL CHARGES
`Prepared by: Mark Lerner, CFE, CPMA, QMC, ICD-10 Proficient
`Cause No.: DC-22:01593 Jamilah Shabazz vs. JA Trucking, LLC and Jerry Lewis Anderson
`
`
`
`

`

`Seven hundred and ninety-four (794) pages of medical and billing records, affidavits, counter-
`affidavits, deposition transcripts, explanation of benefit (EOB) records and/or cover sheets were
`reviewed to provide this report. This counter affidavit addresses only those provider affidavits
`reviewed andaudited prior to the date of this report.
`
`2. RESOURCES
`By way of background, in rendering my opinions on the appropriateness of the coding, billing, and
`fees provided in the cases for which I perform analyses, I rely on many of the following resources,
`including but notlimitedto:
`
`a. Current Procedural Terminolo
`Medical Association or Optum360)
`
`CPT) Professional Edition
`
`(published by
`
`the American
`
`History ofthe CPT
`Physicians and other qualified healthcare professionals (QHPs) need to identify the professional
`services or procedures they provide and to report those services in a way that can be universally
`understood by institutions, private and government payers, researchers, and others interested
`parties. Yearly, healthcare insurers in the United States process more than 5 billion claims for
`payment. This data is used to track healthcare utilization, identify services for payment, and to
`gather statistical healthcare information about populations. To ensure that healthcare data is
`captured accurately and consistently, and that medical claims are processed properly for Medicare,
`Medicaid, and other health programs, a standardized coding system for medical services and
`procedures was needed.
`
`The CPT® (Current Procedural Terminology) system was developed by the American Medical
`Association (AMA)andis used for just these purposes. CPT® provides a standardized language
`and numerical coding system to accurately communicate across many providers,
`insurance
`companies and other payers, saving time and money.
`
`The CPT descriptive terminology and associated code numbers provide the most widely accepted
`medical nomenclature used to report medical procedures and services for processing claims,
`conducting research, evaluating healthcare utilization, and developing medical guidelines and
`other forms of healthcare documentation.
`
`In 1966,the very first publication of the AMA’s (American Medical Association) CPT® (Current
`Procedural Terminology) edition of standardized codes and terms was a means to code mainly
`surgical procedures for medical records, insurance claims, and information for statistical purposes.
`
`The second edition, in 1970, expanded CPT’s® scope. The third and fourth editions were released
`in the 1970’s. The fourth edition was a major update, and introduced a system for periodically
`monitoring and updating CPT.
`
`CPT, in 1983 was adoptedas part of the Health Care Finance Administration (HCFA), Healthcare
`Common Procedure Coding System (HCPCS). This HCPCS codeset is divided into two principal
`subsystems: 1) Level I of the HCPCS, which comprised the CPT codes, and 2) Level I of the
`HCPCS.
`
`
`
`COUNTER-AFFIDAVIT REGARDING REASONABLENESS OF MEDICAL CHARGES
`Prepared by: Mark Lerner, CFE, CPMA, QMC, ICD-10 Proficient
`Cause No.: DC-22:01593 Jamilah Shabazz vs. JA Trucking, LLC and Jerry Lewis Anderson
`
`
`
`

`

`The Health Insurance Portability and Accountability Act of 1996 (HIPAA) required that the
`Department of Health & Human Services develop standards for electronic data storage and
`transmission. Four years later, the Department published the Final Rule, which selected CPT for
`reporting physician services (and other medical services) and International Classification of
`Diseases (9th revision, Clinical Modification), also known as ICD-9-CM for reporting diagnosis
`codes (ICD-10-CM is now the current standard).
`
`CPTStructure
`CPT codesare divided into one of three categories:
`
`Category |
`Category I CPT codes describe distinct medical procedures or services furnished by
`physician’s or other qualified healthcare providers (QHPs) and are identified by a 5-digit
`numeric code [e.g., 99205: New Patient Office or Outpatient Visit, Level 5]. All new Category
`I CPT codes are released annually.
`
`Category Il
`Category Il CPT codes are supplemental tracking codes, also referred to as performance
`measurement codes. These numeric alpha codes [e.g., 2029F: complete physical skin exam
`performed] are used to collect data related to quality of care. Category I codes are released
`three times a year in March, July, and Novemberby the CPT Editorial Panel.
`
`Category III
`Category Ill CPT codes are temporary tracking codes for new and emerging technologies to
`allow data collection and assessment of new services and procedures. They are used to collect
`data in the FDA approval process or to substantiate widespread usage of the new and emerging
`technology to justify establishment of a permanent Category I CPT code. Category HI CPT
`codes are issued in a numeric alpha format[e.g., 0307T: near-infrared spectroscopy study for
`lower extremity wounds].
`
`New Category ITI CPT codesare released biannually (January and July) with a 6-month delay
`before activation for implementation in the Medicare system. Codes released on January 1st
`are effective July Ist, and codes released on July Ist are effective January Ist. The codes
`usually remain active for five years from the date of implementation, if the code has not been
`accepted for placement in the Category I section of CPT.
`
`Obtaining a CPT Level II code requires less clinical data and has a shorter review timeframe.
`It allowsbilling and tracking through the local and regional contractors for Medicare and other
`payers. There are no assigned fees to these codes, but paymentis available at the discretion of
`the Insurance Carriers or Medicare contractors. When considering payment, the Medicare
`contractors and insurers consider evidence of effectiveness, improved outcomes, and potential
`cost savings.
`
`Criteria used by the CPT Advisory Committee and the CPT Editorial Panel for evaluating
`Category III codes for emerging technology includes any one of the following:
`
`1. A protocol for a study of procedures being performed.
`2. Support from the specialties that would use the procedure.
`
`
`COUNTER-AFFIDAVIT REGARDING REASONABLENESS OF MEDICAL CHARGES
`Prepared by: Mark Lerner, CFE, CPMA, QMC, ICD-10 Proficient
`Cause No.: DC-22:01593 Jamilah Shabazz vs. JA Trucking, LLC and Jerry Lewis Anderson
`
`
`
`

`

`3. Availability of U.S. peer-reviewedliterature.
`4. Descriptions of current U.S. trials outlining the efficacy of the procedure.
`
`For the most part, CPT codesare a 5-digit numbering system. CPT codes beginning with a “0” are
`considered anesthesia and can be general, regional, monitored, or conscious sedation. Surgical
`codes in CPT begin with a “1, 2, 3, 4, 5, or 6” and include minor or major procedures. Those
`starting with a 7 are for radiological (ex. x-rays, MRI’s, CT’s, ultrasounds) exams. The radiology
`section typically consists of two parts, one being the professional component, which is appended
`with a modifier -26, and the other being modifier -TC, known as the technical component. The
`professional component (-26) is considered the reading and interpreting of the report by the
`physician or other qualified healthcare provider, while the technical componentis the actual
`“taking” of the MRI, x-ray, etc. In many cases, both components are supplied and billed by the
`same provider. Pathology & laboratory procedures test begin with the number “8.” These can
`include individual tests or in some cases a panel or group oftests using one CPT code.
`
`The number“9” represents two areas, the Medicine section and E/M (evaluation and management)
`code section. The Medicine section uses codes ranging from 90281 through 99607 and can include
`anything from EKGs, coronary or cardiac studies to physical and occupational therapy codes. The
`last part of the “9” section related to E/M codes. These range from 99201 through 99499 and
`included services such as office or outpatient visits, inpatient visits, consultations, and emergency
`department (ED)visits.
`
`Beginning January 1, 2021, there were major changes to coding Evaluation and Management
`services (99201-99215). Per the American Medical Association, CPT code 99201 was deleted, and
`the option by individuals to use either total time on the date of service (DOS) or medical decision
`making (MDM)to select the level of service provided. Time will be defined astotal time spent,
`including non-face-to-face work done on that day, and will no longer require the service to be
`dominated by counseling. Visits will have a range for time, e.g., 99213 will be 20-29 minutes,
`99214 will be 30-39 minutes.
`
`Additionally, there will be no required level of history or examination for visits 9920299215.
`Unlike previous years, neither a history nor exam will be determining factors in selecting the level
`of service for 2021. Furthermore, there will be new definitions within Medical Decision Making
`(MDM). The MDMcalculation will be similar, but not identical.
`
`All other E/M services that are defined by the three key components will continue to use either the
`1995 or 1997 Documentation Guidelines.
`
`b.
`
`International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10
`(published by the American Medical Association, Optum360, or AAPC)
`
`The ICD-10-CM (International Classification of Diseases, Tenth Revision, Clinical Modification)
`is a system used by physicians and other healthcare providers to classify and codeall diagnoses,
`symptoms and procedures recorded in conjunction with hospital care in the United States. It
`providesa level of detail that is necessary for diagnostic specificity and morbidity classification in
`the U.S.
`
`
`
`COUNTER-AFFIDAVIT REGARDING REASONABLENESS OF MEDICAL CHARGES
`Prepared by: Mark Lerner, CFE, CPMA, QMC, ICD-10 Proficient
`Cause No.: DC-22:01593 Jamilah Shabazz vs. JA Trucking, LLC and Jerry Lewis Anderson
`
`
`
`

`

`ICD-10-CM is based on the International Classification of Diseases, which is published by the
`World Health Organization (WHO)and whichuses unique alphanumeric codesto identify known
`diseases and other health problems. According to WHO, physicians, coders, health information
`managers, nurses and other healthcare professionals also use ICD-10-CM to assist them in the
`storage and retrieval of diagnostic information. ICD records are also used in the compilation of
`national mortality and morbiditystatistics.
`
`All Health Insurance Portability and Accountability Act (HIPAA)-covered entities must adhere to
`ICD-10-CM codes, as mandated by the U.S Department of Health and Human Services (HHS).
`
`ICD-10 Code Structure
`The structure of ICD-10-CM codesis as follows: The first character must be an alpha character,
`excluding "u.". The second andthird characters are numeric, and characters four through seven
`can be a combination of numeric and alpha characters.
`
`Thefirst three characters categorize the injury, and the fourth through sixth characters describe in
`greater detail the cause, anatomical location and severity of an injury orillness. For certain codes,
`a seventh character is an extension digit and used to classify an initial, subsequent or sequela (late
`effect) treatment encounter. ICD-10-CM also uses a placeholder character "X"to allow for future
`expansion of certain codes.
`
`CMS guidelines state that diagnosis codes are to be used and reported at their highest number of
`characters available and that three-character codes should only be used if it
`is not further
`subdivided. A code will be considered invalid if it has not been coded to the full number of
`characters required, including a seventh character if applicable.
`
`ICD-10-CM is also divided into an alphabetical index and a tabularlist. The alphabetical index is
`an alphabetical list of terms and the corresponding codes, and the tabularlist is a structuredlist of
`codes that is divided into chapters that are based on a body system or condition.
`
`ICD-9-CM versus ICD-10-CM Code Sets?
`The U.S. had been using ICD-9-CM since 1979 and the coding scheme wasnotsufficiently robust
`to serve the health care needs of today and into the future. The content is no longerclinically
`accurate, the numberof available codes was limited and had been maxed out for somecategories,
`and the coding structure was too restrictive. Further, mortality coding (death certificates) in the
`U.S. moved to ICD-10 in 1999 so the U.S. could not directly compare morbidity diagnosis data to
`state and national mortality data. Similarly, most other developed countries had already
`transitioned to ICD-10 (for morbidity applications) so the U.S. could not directly compare
`morbidity diagnosis data at the international level.
`
`Updates
`ICD-10-CM codesare updated every year, and available typically in September or October of the
`preceding year(1.e., 2021 codes available in September or October of 2020).
`
`General Equivalence Mappings (GEMs)
`GEMsarea toolthat can assist with converting data from ICD-9-CM to ICD-10-CM. GEMsare a
`reference map, a practical reference dictionary to help a user navigate the complex meaning
`between the codesets. For example, one ICD-9-CM code can be represented by multiple ICD-10-
`
`
`COUNTER-AFFIDAVIT REGARDING REASONABLENESS OF MEDICAL CHARGES
`
`Prepared by: Mark Lerner, CFE, CPMA, QMC, ICD-10 Proficient
`Cause No.: DC-22:01593 Jamilah Shabazz vs. JA Trucking, LLC and Jerry Lewis Anderson
`
`|
`
`

`

`CM codesand the GEMsshowall of the possible alternative translations. Another example is that
`some concepts exist in [CD-10-CM that did not exist in ICD-9-CM, such as the Glasgow Coma
`Scale to assess level of consciousness. GEMscontain forwards and backwards mappings between
`ICD-9-CM and ICD-10-CM, and forward and backward mappings between ICD-9-CM and
`ICD10-PCS. There are many GEMsfiles within each of the mapping categories. The GEMswere
`developed by the Centers for Medicare and Medicaid Services and CDC’s National Center for
`Health Statistics. Please note that GEMs between ICD-10 (World Health Organization version)
`and ICD-10-CM/PCSwill be forthcoming.
`
`Lastly, ICD diagnostic codes link with CPT codes and HCPCScodesto further confirm medical
`necessity.
`
`ec. National Correct Coding
`Services)
`
`Initiative
`
`(published by
`
`the Centers for Medicare and Medicaid
`
`The Centers for Medicare and Medicaid Services (CMS) developed the National Correct Coding
`Initiative (NCCI), also known as CCI Edits,
`in 1996 to promote national correct coding
`methodologies and to prevent Medicare administrative contractors (MACs) from paying for
`duplicative or overlapping services, and to encourage compliant coding. Often called “Column
`One/Column Two”edits, they are largely based on coding rules, conventions, and guidelines
`defined in the American Medical Association's CPT Manual, plus national and local policies and
`edits, coding guidelines developed by national societies, analysis of standard medical and surgical
`practices, Medicare’s fee schedule’s relative value system, and on national and local health
`insurance policies and claims edits, and a review of current coding practices. The CMS annually
`updates the National Correct Coding Initiative Coding Policy Manual for Medicare Services
`(Coding Policy Manual). The Coding Policy Manual should be utilized by carriers and Fiscal
`Intermediaries (FI’s) as a general reference tool that explains the rationale for NCCIedits.
`
`All carriers, whether Medicare or Medicaid utilize the NCCI edits developed by CMS.
`
`d. Medically Unlikely Edits (published by the Centers for Medicare and Medicaid Services)
`
`The CMS developed Medically Unlikely Edits (MUEs)to reduce the paid claimserror rate for Part
`Bclaims. An MUEfor a HCPCS/CPTcode is the maximum units of service that a provider would
`report under most circumstances for a single beneficiary on a single date of service. All
`HCPCS/CPTcodes do not have an MUE.
`
`MUEwasimplemented January 1, 2007, and is utilized to adjudicate claims at Carriers, Fiscal
`Intermediaries, and DME MACs.
`
`e. National Fee Analyzer published by OptumInsights
`
`The National Fee Analyzer includes three percentiles of national charge data as well as locality-
`specific Medicare allowables for CPT codes. Data is obtained and reprinted from real-life claims
`from the FAIR Health database of more than twenty-five billion (25,000,000,000) claims, with
`more than one billion, seven hundred thousand (1,700,000,000) new claims each year. Includes
`geographic conversion factors adjusting national averages for specific geographic areas across the
`country with one resource for both commercial and Medicare.
`
`
`COUNTER-AFFIDAVIT REGARDING REASONABLENESS OF MEDICAL CHARGES
`Prepared by: Mark Lerner, CFE, CPMA, QMC, ICD-10 Proficient
`Cause No.: DC-22:01593 Jamilah Shabazz vs. JA Trucking, LLC and Jerry Lewis Anderson
`
`
`
`

`

`FAIR Health is a national, independent, not-for-profit corporation whose mission is to bring
`transparency to healthcare costs and health insurance information.
`
`f. HCPCS Fee Analyzer published by OptumInsights
`
`The HCPCSFee Analyzer provides four levels of national charge data as well as locality-specific
`Medicare allowables for HCPCS codes. This resource, like the National Fee Analyzer can assist
`in setting fees, evaluating reimbursements by payors, plus the HCPCS Fee Analyzer can aid in the
`negotiation with DMEPOS (durable medical equipment, prosthetics, orthotics, and supplies)
`suppliers. The four levels of charge data are the 25th, 50th, 75th, and 85" percentile, and are
`derived from the FAIRHealth Database of 600+ million current HCPCS charge records. If utilized
`in this report, only the 50", 75" and 85"percentiles will be displayed and placedinto the 50", 75"
`and 90"percentile.
`
`g. Texas PT Practice Act; Texas Board of Physical Therapy Examiners — Title 3, Subtitle H,
`Chapter 453 — Occupational Codes
`
`h. American Physical Therapy Association Guidelines
`Guidelines: Physical Therapy Documentation ofPatient/Client Management
`
`i. Centers for Medicare and Medicaid Services
`Medicare Benefit Policy Manual — Chapter 15 — Covered Medical and Other Health Services, 220.3.E
`
`j- ChiroCode
`
`k. Novitas-Solutions Website
`
`l. Drugs.com Website
`
`m. RXPricequotes.com Website
`
`n. GoodRX.com Website
`
`o. Texas Department of Insurance
`
`p- Healthcare Bluebook
`
`q. New Health Choice
`
`r. CMSData.gov
`
`s. CMS Medicare Claims Processing Manual (Publication #100-04
`
`t. Texas Department of State Services — EMS/Trauma Systems
`
`u. North Central Texas Trauma Regional Advisory Council
`
`
`
`COUNTER-AFFIDAVIT REGARDING REASONABLENESS OF MEDICAL CHARGES
`
`Prepared by: Mark Lerner, CFE, CPMA, QMC, ICD-10 Proficient
`Cause No.: DC-22:01593 Jamilah Shabazz vs. JA Trucking, LLC and Jerry Lewis Anderson
`
`al
`
`

`

`v. Trauma Activation Guidelines — Texas EMS Trauma & Acute Care Foundation
`
`w. Texas PricePoint Website
`
`x. Area Hospital and Surgery Center Charges from:
`Advanced Diagnostic Healthcare System — Houston
`Ascension Seton Medical Center Austin
`Austin North Medical Center
`Baptist Health Systems
`Baptist Medical Center — San Antonio
`Baylor Scott White — Arlington
`Baylor Scott White — Grapevine
`Baylor Scott White - McKinney
`Baylor Scott White — Plano
`Baylor Scott White — Sherman
`Baylor Scott White — Sunnyvale
`Baylor Scott White — Texas Spine & Joint - Tyler
`Baylor Scott White — Waxahachie
`Baylor University Medical Center — Dallas
`Binz Surgery Center — Houston
`BSA Hospital — Amarillo
`CapRock Hospital — Bryan
`Carrollton Regional Medical Center
`Carrus Health — Sherman
`Cedar Park Regional Medical Center
`Central Park Surgery Center — Dallas, Texas
`Chi St. Luke’s Baylor - Houston
`Chi St. Luke’s Baylor - Sugarland
`Chi St. Luke’s - Sunnyvale
`Christus Health Mother St Francis — Tyler
`Christus Santa Rosa — San Antonio
`City Hospital at White Rock
`Cook Children’s Hospital — Fort Worth
`Crescent - Lancaster
`Dallas Medical Center
`Del Sol Medical Center - El Paso
`DFW North Central Surgical Center
`EncompassRehabilitation Hospital of Dallas
`Foundation Surgical Hospital — San Antonio
`Harris Health Ben Taub Hospital — Houston
`HCA Healthcare
`HCA Hospital - Kingwood
`HCATexas Orthopedic
`Houston Neurological Institute
`Houston Pain and Spine
`Houston Physician’s Hospital
`Huebner Surgery Center
`Hunt Regional Medical Center
`John Peter Smith Hospital — Fort Worth
`John Peter Smith — Grapevine
`Kindred Hospital Dallas
`
`
`COUNTER-AFFIDAVIT REGARDING REASONABLENESS OF MEDICAL CHARGES
`Prepared by: Mark Lerner, CFE, CPMA, QMC, ICD-10 Proficient
`Cause No.: DC-22:01593 Jamilah Shabazz vs. JA Trucking, LLC and Jerry Lewis Anderson
`
`

`

`
`
`Kingwood Emergency Hospital
`Las Palmas Medical Center - El Paso
`LifeCare Hospitals of Dallas
`LifeCare Hospitals of Plano
`Limestone Medical Center — Groesbeck
`Lone Star Surgery Center — Austin
`LoneStar Surgery Center — Houston
`Longview Regional Medical Center
`MD Anderson - Houston
`Medical Center Hospital — Odessa
`Medical City — Arlington
`Medical City — Dallas
`Medical City — Frisco
`Medical City — Lewisville
`Medical City North Hill - NRH
`Medical City — Plano
`Memorial Hermann - Houston
`Memorial Hermann — Northeast
`Memorial Hermann - Sugarland
`Methodist Charlton Hospital — Dallas
`Methodist Dallas Medical Center
`Methodist Hospital - HEB
`Methodist Hospital - McKinney
`Methodist Hospital — Richardson
`Methodist Hospital — Southlake
`Methodist Healthcare — San Antonio
`Methodist Texas Medical Center — Houston
`Midland Memorial Hospital - Midland
`Mitchell County Hospital - Colorado City
`Navarro Regional Medical Center — Corsicana
`North Central Surgery Center
`NTTC Surgery Center
`Odessa Regional Medical Center — Odessa
`Palestine Regional Medical Center
`Parkland Hospital - Dallas
`Parkland Pharmacy- Dallas
`Park Plaza Hospital — Houston
`Parkview Regional Hospital —- Mexia
`Parmer Medical Center - Friona
`Paris Regional Medical Center - Paris
`Physicians Surgical Hospital - Amarillo
`Pine Creek Medical Center - Dallas
`Plano Surgical Hospital
`Preston Surgery Center
`Promise Hospital — Dallas
`Promise Hospital Pharmacy- Dallas
`Rolling Plains Memorial Hospital - Sweetwater
`Saint Camillus Medical Center — Hurst
`San Antonio Regional Hospital
`Scenic Mountain Medical Center — Big Springs
`Scottish Rite Hospital
`SE Texas ER & Hospital
`
`
`COUNTER-AFFIDAVIT REGARDING REASONABLENESS OF MEDICAL CHARGES
`Prepared by: Mark Lerner, CFE, CPMA, QMC, ICD-10 Proficient
`Cause No.: DC-22:01593 Jamilah Shabazz vs. JA Trucking, LLC and Jerry Lewis Anderson
`
`

`

`Shannon Medical Center - San Angelo
`South Texas Health Systems
`South Texas Spine and Surgical Hospital
`Southwest General Hospital — San Antonio
`St. David’s Medical Center - Austin
`St. Joseph’s Medical Center
`Stephens Memorial Hospital — Breckenridge
`Texas Brain and Spine Center - Webster/Lake Jackson
`Texas Health Resources — Dallas
`Texas Health Resources - Denton
`Texas Health Resources — Flower Mound
`Texas Health Resources — Frisco
`Texas Health Resources — HEB
`Texas Health Resources — Kaufman
`Texas Health Resources — Plano
`Texas Health Resources — Rockwall
`Texas Institute for Surgery — Dallas
`Texas Medical Management — Austin
`Texas Orthopedic Hospital — Houston
`The Hospital of Providence — El Paso
`The Physician’s Centre Hospital — Bryan
`Tops Surgical Specialty Hospital — Houston
`University Health Systems — San Antonio
`University Medical Center - El Paso
`USMD- Arlington
`UT Health — Athens
`UT Health — Henderson
`UT Health - Tyler
`UT MD Anderson — Houston
`UT Southwestern Hospital
`Wilson N. Jones Regional Medical Center - Sherman
`
`y. Area Ambulance and EMSServices
`Care Flight
`City of Austin EMS
`City of Bowie - Wise FD EMS
`City of Carrollton EMS
`City of Cleburne EMS
`City of Dallas EMS
`City of El Paso Fire/EMS
`City of Garland EMS
`City of Houston EMS
`City of Irving EMS
`City of Mesquite EMS
`City of Odessa Fire Rescue EMS
`City of San Antonio EMS
`City of Stephenville EMS
`Wise County EMS
`
`z. Anesthesia Providers
`Lakewood Anesthesia
`Metro Anesthesia
`
`
`COUNTER-AFFIDAVIT REGARDING REASONABLENESS OF MEDICAL CHARGES
`Prepared by: Mark Lerner, CFE, CPMA, QMC, ICD-10 Proficient
`Cause No.: DC-22:01593 Jamilah Shabazz vs. JA Trucking, LLC and Jerry Lewis Anderson
`
`

`

`USAP
`USAS
`
`It is usual and customary within the medical expense coding profession to consider and/or rely
`upon the above-referenced sources of information.
`
`Fees for the type of analysis I do are obtained from various sites and publications including, but
`not limited to the National Fee Analyzer, published by Optum360, Healthcare Bluebook, Hospital
`Chargemasters, and through use of emails, internet, and phone calls. The data used in the National Fee
`Analyzer book and FeeAnalzer.com are obtained from FairHealth. FairHealth is a national, independent,
`not-for-profit corporation whose missionis to bring transparency to healthcare costs and health insurance
`information. They have compiled an independent database of information from healthcare claims
`contributed by payers nationwide, and used by consumers, health plans, policymakers,
`insurers,
`governmentofficials, bill reviewers and administrators, healthcare systems, hospitals and other facilities,
`healthcare providers, pharmaceutical companies, researchers, and consultants. This information is used to
`determine the usual, customary, and reasonable rates for each specific geographical region in the U.S.,
`Puerto Rico, and the Virgin Islands. FairHealth presently uses data from more than 25 billion private
`healthcare claims (1.7 billion new records each year), 16 years of claim data, and have broken downthis
`data into 493 distinct geographic regions, assigning a set fee for each CPT code along with a unique
`geographical price cost index adjustment facto