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May 12, 2008

The Visible Black Character — What You See Is What You Get ... Or Not
By Linda M. Sullivan
For The Record
Vol. 20 No. 10 P. 6

A visible black character is a visible black character is a visible black character. Right? Yes ... well, maybe.

Last year, the Joint Task Force on Standards Development of the AHIMA and the Medical Transcription Industry Alliance (MTIA) presented a white paper, “A Standard Unit of Measure for Transcribed Reports,” that recommended the visible black character (VBC) become the standard unit of measure for counting and billing methodologies. There has not been an industry standard since the Association for Healthcare Documentation Integrity, then known as the American Association for Medical Transcription, withdrew its support of the 65-character line in 1998. Now, the the AHIMA and MTIA have taken a step in the right direction by creating a process that should be transparent.

While a standard has been sorely needed and the VBC is probably as good as it gets, any counting method, including the VBC, can be manipulated. For example, confusion can occur when an interface exists between a medical transcription service organization (MTSO) platform and an electronic medical record (EMR) because it can be difficult to ascertain exactly what is being counted as a VBC.

Recently, a client asked New England Medical Transcription—one of three vendors providing services to its facility—to submit line count, VBC count, and billing for several documents. In an effort to understand what was being delivered to our client, our platform counts for lines and VBCs were examined by myself and the IT staff. We delved into how those numbers were derived and examined what was delivered.

The numbers jived with the client’s—but not exactly. However, our figures were closer than the other two transcription vendors, which was a relief; I didn’t know how our numbers would compare since they were looking at the documents at a different point in the process.

What you see on the page becomes murky when you start looking at the many factors involved in creating a document for a client. Items such as headers and footers, templates, forms, and signature lines can contribute to a difference between a client’s count and the MTSO’s count. And what about the demographic data that are sent via admission, discharge, transfer to the MTSO and then sent back to the client via Health Level Seven interface? At what point are the VBCs counted—when it is sitting in the EMR or when it is printed (if it ever is)?

Any standard of measure can be manipulated. What is important is that the relationship and the agreement between the MTSO and the healthcare facility be open and honest and that there is agreement on exactly what is being counted and when. It is essential that all medical facilities—which should understand the process as well as MTSOs do—have this conversation with their transcription vendor.

Financial Ramifications
When the AHIMA/MTIA white paper was published, I received an e-mail from a fellow transcription service owner stating that this standard was either going to put us all out of business or, at the very least, cost us a huge chunk of change.

Transcriptionists, too, are concerned that the VBC means a pay cut. Many believe that now they won’t be paid for spaces, which means they would produce the same amount of work for less money. The intent of having a standardized and verifiable counting-and-billing method is not to pay less or charge less. Rather, the intent is to put to rest the big question that many facilities have: What are we being billed for? That should not be an issue if we all understand that the VBC is supposed to be about a verifiable measurement and not about changing pricing.

The downward pricing pressure in the transcription industry doesn’t leave a lot of room for a pay cut for anyone. No one is being overpaid to provide transcription services, particularly transcriptionists. Nevertheless, in most cases, transcription is viewed by the financial folks as a line item in the annual budget that can be cut. Items such as transcription, which are not inviolate, are looked at as opportunities to bring costs down—never mind that transcription drives the billing process and, therefore, receivables. As a result, when a service owner or a transcriptionist hears that they’re only going to be paid for VBCs, it sounds scary.

But this doesn’t have to be. What we need to understand is that MTSOs have no intention of billing their clients less while, at the same time, they should not be paying their transcriptionists less. The word counting function in Word can be used to approximate what the charge should be for the VBC that is comparable to what was being paid/charged for the 65-character line, including spaces.

For example, a 100-line document for which the medical transcriptionist is paid 8 cents per line results in a total price of $8. To make the conversion from a 65-character line (what many services have billed on and paid for) to essentially a 65-character line without spaces, divide the total number of characters in a document with spaces by 65 and multiply by 52.2; the total is the number of black characters. Then divide $8 by the number of characters (80.38) for the per character rate of .099.

Sample Document
6,500 characters with spaces
5,222 with no spaces
100 ÷ 65 X 52.2 = 80.307 characters
$8 ÷ 80.307 characters = .099 cents per character

Whatever method is used, the point is to have a verifiable method of counting and billing while not changing anyone’s rate of pay or the amount charged to the client.
Where do we go from here with the VBC? It should be embraced by the medical transcription community and used to enhance and clarify delivery of patient reports.

— Linda M. Sullivan is president of New England Medical Transcription Inc. and was the founding coordinator and first president of the Pine Tree Chapter of Maine, a chapter of the Association for Healthcare Documentation Integrity. She is also past president of The New England Association for Medical Transcription.