where does revenue come from in private practice?
comes from your office codes 99202 to 99215, hospital codes 99221 - 99233 (if you round in the hospital), procedure CPT codes, and certain quality metric CPT codes (G2211 for complex care, G0420 for discussion about CKD care/manaegment, G0296 for discussion for lung cancer screening just to name a few).
the internist bills the same office and hospital codes as the subspecialists in IM
the internist usually has a few CPT codes to use in the office such as 93000 EKG, 36415 venous phelbotomy, 81002 U/A dipstick, 94664 inhaler etchnique, 94010 basic spirometry, 92552 pure tone audiometry (yes you can thank me later internists who never thought of this. i got inspired when I saw my kids pediatrician office using this device), and maybe a few others. But no "real procedures" for internal medicine
the specialists will vary
the nephrologist does not really any office based CPT codes different than what the internist could order. Oh sure one could get certified in diagnostic renal U/S and do a 76705, write a report, and collect a cool $100 or so (more than cardiologist's TTE) but that is the exception and not the norm. The nephrologist's key procedural CPT code is dialysis and can include chronic HD, acute inpatient HD, CRRT, home HD, and PD.
But what is the rate limiting factor for these procedures? the ESRD (or AKI requiring RRT for hospital patients) patient. These patients do not "grow on trees." These patients can be considered a "rare commodity." THose top ten% neprhologists who make a lot of money have a lot of this "rare commodity."
in contrast other IM subspecialties can do their procedure CPTs on every patient that walks in the door if desired
everyone gets an echo, EKG, treadmill stress with the cardiologist. then onto the nuclear money print machine, get a US carotid , US LEA, and Holter while you're at it.
everyone gets an EGD and colonoscopy with the GI doctor
everyone gets chemo or immuntoherapy with the oncologist (usually right?)
everyone gets PFTs and certain other tests with the pulmonologist.
just to name a few.
not everyone who walks into endocrine needs thyroid FNA or DEXCOM remote patient montioring
not everyone who walks into ID gets... anything beyond the office visit code
not everyone who walks into rheum gets an arthrocentesis or steroid injection or MSK ultrasound or biologic infusion.
so the logic comes out to be -
why do a tough renal fellowship that in some ways rivals cardiology in acuity (perhaps no CCU equivalent but no less daunting) but not get any promise of that rainbow and pot of gold?
sure money is not everyone's thing. so do a non procedure IM subspecialty then.
Renal without HD is not a viable career path unless you do GIM / hospitalist with renal knowledge as a secondary to "help yourself with tougher primary care / hospitalist patient cases." even then teh two year opportunity cost is nothing to scoff at.