“The starting salary for a new graduate can range from $175,000 to $225,000”
Nephrology can be a rewarding career path. Learn more about pursuing a career in nephrology and what it takes to provide kidney patients the best care.
fmcna.com
This is from the fresenius website. In a way this is “straight from the horses mouth .”
Because the HD corporations own all of the chronic HD , you cannot hope to “start your solo practice “ and practice HD unless you have a connection in the corporate field or your family / friend is the senior partner who will promote you quickly.
therefore the best one can hope for after graduating nephrology (in terms of revenue generation, lifestyle, and prevention of burnout) and not pursuing academics is to be a PMD/privileges for IM admissions and do all of the renal minus HD .
Although I agree with everything Renal Prometheus has outlined over the years, I am just trying to provide the glass half full approach to the situation for those renal fellows or renal graduates who find themselves stuck in this quagmire.
Also Academic Renal Medicine is a wonderful career. Money isn't everything in life. But the academic doctors need to realize that academic positions are LIMITED and not every graduating renal fellow can even have the opportunity to become an academic doctor (much less deal with the publish or perish environment in an academic job)
If you were successful in launching your own private practice, perhaps with the savings you made from a few years of hospitalist work or from working as an indentured servitude position for the greedy old dinosaur private practice doctors (honestly they have no incentive to give you money unless you are family/friend/or both), then here is what to expect:
- You will be unable to work as a traditional nephrologist. You will not be able to obtain HD privileges for yourself at the local HD center or obtain hospital dialysis privileges. This is purely due to limited revenue and the desire for the hospitals/HD corporations to consolidate all revenue to a select few.
- You will likely not be given privileges to a local infusion center. Do not expect to practice glomerulonephritis by yourself unless you eventually set up your own office infusion center. This is not likely unless you build your own group of "partners."
- You will likely not receive many referrals unless you go out and about to advertise yourself.
- You are unlikely to receive nephrolithiasis referrals unless you advertise yourself to a urologist.
- You are unlikely to receive hypertension referrals unless you advertise yourself to cardiologists.
But you should expect (and build your practice) should be primary care / internist who can also see his/her own patients for nephrology related issues. You will occasionally get the nephrology referral from another physician. In this model, the nephrology is purely value added. Insurances list you as both but label you as PMD. The Internist business you get is what it is. The nephrology aspect becomes some kind of additional revenue stream.
If you can serve a "underserved" Managed Medicare/Medicaid population, these patients tend to have low deductibles and low or no copay/coinsurance. Translation - you can see them as much or as little as the patient needs or wants and collect each visit. Just be sure the visit is appropriate in case someone comes to audit you.
The pros are you can totally not even bother to go to the hospital (unless you want to admit a patient under yourself as internist) because having non-HD renal consulting privileges is like skydiving without your backup parachute. Also, this allows you to not have to deal with the headaches of chronic HD as outlined above.
- You can manage Ckd and vascular access up until the last minute in ckd5 , then admit under yourself as internist and call the hospital nephrologist to initiate HD and have the social worker plug that person in . You can use your renal training as additional volume to your primary care practice and not have to deal with the esrd headaches (missed HD , vascular access issues , etc ...)
- You can obtain formal training in renal ultrasonography and perform point of care renal ultrasonography. Insurances do not require formal certification / documentation to perform and bill for point of care studies. But you better know what you're doing and documenting in the event of a lawsuit. But this can be counteracted if you simply send for a CT / MRI if you see any concerning morphological findings.
Point of care U/S are very cheap. The Butterfly IQ is very economical for this purpose.
- You can perform 24 hour ABPM testing. This is essentially analogous to what a cardiologist does with Holter. Only thing is, you don't need any special certification from ASH or any governing body to perform this.
- You could set up urine lab... if the labwork shows hematuria and proteinuria - go for it and find the acanthocytes or casts. Amazon has some very economic phase contrast microscopes that have camera attachments that can connect to a computer for image capture.
In addition to the office codes 99202-5 and 99211-99215, the other major CPT codes that an office Nephrologist can performed (and collect fully on if you own your own practice)
G0421 - CKD education for an individual = up to an hour - Medicare fee schedule $136.49 - really give that talk about CKD, diet, meds, access, what to expect, etc... this can be billed on top of the office code if other E/M services were done (especially if you are the PMD and did other E/M for other issue)
76705 - POCUS Abdomen - do a bladder / kidney - use this code. caution as above. Medicare fee schedule 116.64. Commercial insurance (assuming deductible/out of pocket met) pays up to $230.
96401 - this code was meant for chemotherapy administration SQ/IM. But certain injectable agents like the ESA agents can also use this code for billing purposes. Whether the insurance pays you or not for this code is insurance specific. Medicare $103.87.
96372 - otherwise this is the code for injecting medications. $21.15
93784 24 hour ABPM with software / interpretation / report - $68.75
(I am not bothering to list the CPT codes for urinalysis and manual microscopy because that is on the order of a few dollars and you need CLIA certification - which is not that hard to do - but it's a lotta paperwork for a few measly bucks only)
Since you are the PMD, you can also do many of the PMD codes to really get things to add up.
Let's just take a hypothetical situation of you are the PMD/nephrologist for a 65+ year old patient with current smoker CKD4, CHF, T2DM, HTN, CAD, HLD, etc... the usual. who has Managed Medicare (this means Medicare + another insurance like UHC or one of the other companies)
Annual Physical to go over all medical issues and update screening 99397 - $180.00
12 Lead ECG as indicated given all of these comorbidities 93000 - $30
Annual depression screening G0444 - $22.95
Tobacco cessation counseling 3-10 minutes 99406 - $18.65
Palliative care discussion - doesnt have to be you signed a MOLST form - as long as this is an earnest conversation - 99497 - $105.65
Basic spirometry with flow volume loop (dont need to be a pulm to do this) 94010 - $60.00
Now tack on the value added nephrology items
76705 - $116.64
G0421 - $136.49
96401 - $103.87 (gave Procrit or something)
93784 - $68.75
What does this sum up to?
$843.00
Now these are charges and depending on how well you (or your IPA) negotitated with the specific insurance carrier, you might see up to 70% of the charges collected.
So in the ballpark of $500-$600 for this visit.
A simple 99213 usually pays about $80-100 when factoring in coinsurance/copay.
Not every patient is going to merit billing all of those codes or doing all of those things. But this example just serves to highlight how one can make lemons from lemonade for those who are stuck in renal fellowship (and do not want to be an academician) or graduated and are wondering how to make something out of your renal certification from a business standpoint.
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