Chronic care management (CCM) for Podiatry: Managing Podiatric Conditions Between Visits

Mrs. Alvarez is a 72-year-old with diabetes, peripheral neuropathy, and a history of foot ulcers. She visits her podiatrist every 10 weeks for routine care. Between visits, small wounds can progress, sensation may fade further, and vascular changes can develop silently. By the time problems are obvious, the next podiatry appointment might be weeks away.

This is where Chronic Care Management (CCM)—billed by an eligible supervising practitioner—closes the gap with structured, documented monthly outreach to monitor symptoms, coordinate care, and trigger timely intervention before damage sets in.

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Chronic Podiatric Conditions Relevant to CCM

Patients with chronic foot and ankle issues often meet CCM eligibility, particularly when those issues coexist with other systemic illnesses. Podiatrists care for a wide spectrum of chronic conditions affecting the feet, ankles, and lower extremities. Many of these conditions occur alongside systemic illnesses, meeting CCM’s eligibility requirement for two or more chronic conditions expected to last at least 12 months and posing significant risk if unmanaged. CCM is defined as a non–face-to-face care coordination service that requires documented patient consent, a patient-centered electronic care plan, and 24/7 access for urgent needs.

While podiatrists (DPMs) cannot bill CCM directly under Medicare, they are often the first clinicians to detect early changes or deterioration. Their findings—when shared with a supervising billing practitioner such as an MD/DO, NP, PA, CNS, or CNM—help ensure foot and ankle concerns are addressed in the broader chronic care plan under CCM.

Common chronic podiatric conditions that fit the CCM context include:

• Diabetes-related foot complications: Diabetic neuropathy, peripheral artery disease (PAD), chronic wounds or ulcers, and infection risk. Podiatrists focus on prevention, early detection, and advanced wound care to avoid amputation.
• Arthritis: Rheumatoid arthritis (RA) and osteoarthritis (OA) can cause persistent joint pain, deformities, and mobility problems in the feet and ankles. Management includes pain control, orthotics, surgical solutions, and mobility support.
• Peripheral artery disease (PAD): Common in patients with diabetes and cardiovascular disease, PAD reduces circulation, raising the risk of non-healing wounds and tissue loss. Podiatrists aid in diagnosis, wound care, and vascular referrals.
• Chronic wounds and ulcers: Especially prevalent in those with diabetes, vascular disease, or limited mobility, requiring specialized wound care techniques and limb preservation strategies.
• Chronic foot and ankle deformities: Bunions, hammertoes, heel spurs, pes planus (flat foot), and pes cavus (high arch) can become chronic and often require surgical or orthotic interventions.
• Obesity-related foot issues: Ongoing stress on the lower extremities can lead to pain, plantar fasciitis, and joint degeneration. Podiatrists provide management plans and mobility aids.
• Chronic skin and nail disorders: Onychomycosis, recurrent calluses, corns, and ulcer-prone skin need continuous monitoring and treatment.
• Chronic kidney disease complications: Swelling, reduced circulation, and heightened infection risk in the feet require careful podiatric monitoring.
• Neuromuscular and structural conditions: Neuropathy from diabetes or other causes, gait disorders, chronic pain syndromes, and repetitive stress injuries affecting foot and ankle function.

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Viewed through the CCM lens, these conditions are not isolated problems of the foot; they are the downstream expression of systemic disease that benefit from monthly, team‑based follow‑up.

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The Link to Diabetes and Why It Matters

Hyperglycemia injures peripheral nerves and microvasculature, leading to loss of protective sensation, autonomic skin changes, and impaired wound healing. Add PAD, and small pressure points can quickly develop into ulcers that spiral into infection and, in severe cases, amputation. Guidelines from the American Diabetes Association (ADA) and the International Working Group on the Diabetic Foot (IWGDF) emphasize routine foot risk assessment, patient education, footwear optimization, and early referral for any pre-ulcerative lesion—because deterioration can occur between clinic visits.

Monthly CCM touchpoints make that guidance actionable. Care coordinators can:

• Check for new skin changes
• Reinforce off-loading and proper footwear
• Confirm follow-up with vascular or wound clinics
• Escalate urgent concerns immediately

With roughly 160,000 diabetes-related amputations annually in the U.S. and a majority of non-traumatic lower limb amputations linked to diabetes complications, closing the time gap between podiatry visits is critical. By operationalizing prevention in the weeks between in-person visits, CCM lowers the odds that a small issue turns into a catastrophic outcome.

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How CCM Activities Support Podiatric Outcomes

CCM’s monthly, non–face-to-face services can be tailored to foot health while anchoring them to whole-patient goals. Instead of treating the foot in isolation, CCM incorporates podiatric concerns into the same workflow used to manage the patient’s other chronic conditions.

Examples of CCM activities relevant to podiatry include:

• Care plan updates with podiatric input: After podiatry visits, the supervising care team updates the shared care plan with wound status, footwear changes, off-loading recommendations, and red-flag criteria.
• Targeted monthly assessments: Coordinators ask about skin integrity, drainage, new calluses, warmth, swelling, changes in sensation, or footwear issues. Early pattern recognition leads to rapid in-person evaluation before infection sets in.
• Medication reconciliation with a circulation/neuropathy focus: CCM teams confirm adherence to medications affecting perfusion, neuropathic pain, or glycemic control, alerting the supervising provider to needed changes.
• Proactive scheduling and reminders: Coordinating imaging, vascular consults, wound care, and diabetic shoe fittings helps avoid missed appointments that could lead to complications.
• Fast-track referrals: When problems are flagged, the podiatrist, vascular surgeon, or wound clinic is contacted with the necessary background for immediate intervention.

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Delivered every month, these steps create a safety net that lowers the chance of silent deterioration between visits. While specific effect sizes vary by population and workflow, this approach aligns with ADA/IWGDF prevention principles.

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Billing Considerations: The Podiatrist’s Role

Medicare designates CCM as outside the scope of limited‑license practitioners, including podiatrists, so DPMs cannot bill CCM. Only one eligible practitioner may bill CCM per patient per calendar month and billing must be done by an eligible MD/DO, NP, PA, CNS, or CNM. Podiatrists remain essential contributors: they identify risk, document findings, and advise the care plan; the supervising billing practitioner’s team executes the monthly coordination and documentation. This division of labor preserves compliance while amplifying podiatry’s clinical impact.

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Implementation Strategy: Primary Care and Podiatry Partnership

Here are four key steps for a sound implementation strategy for CCM in a podiatric context.

Step 1: Identify eligible patients. Podiatrists flag patients with chronic foot disease plus at least one additional qualifying condition (e.g., diabetes + PAD). The list is securely shared with the supervising team.

Step 2: Build joint care plans. Include ulcer prevention goals, footwear/off‑loading, callus and nail care, and surveillance cadence alongside diabetes, CKD, or hypertension targets.

Step 3: Conduct meaningful monthly contacts. Use podiatry‑informed scripts to assess foot status, reinforce education, and schedule follow‑ups; document consent, time, and actions to meet CCM rules.

Step 4: Close the loop quickly. Any red flags trigger expedited podiatry/vascular/wound evaluation, with updates pushed back into the care plan.

This collaboration keeps foot health visible within the broader chronic‑care picture and aligns with guideline‑based prevention. The result is a tighter, safer continuum of care, without changing how podiatrists bill.

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ROI and Outcome Potential

Avoiding a single major amputation can avert substantial acute‑care and rehabilitation costs and preserves mobility, independence, and survival—5‑year mortality after major amputation is high in multiple cohorts, underscoring the value of prevention. While CCM itself is a coordination benefit rather than a wound‑care service, its monthly monitoring, timely referral, and adherence support operationalize ADA/IWGDF recommendations that are associated with fewer severe complications. Local results will depend on patient mix and fidelity to workflows.

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From a financial standpoint, preventing even one major amputation may save thousands of dollars in acute care and rehabilitation, while also supporting value‑based metrics. For patients, the value is life‑changing: preserved independence, fewer procedures, and a steadier path to wellness.

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Common Pitfalls And How to Avoid Them

Some of the common issues are:

• Siloed EHRs: Without shared access, foot health updates may not reach the care team in time.
• Non-specific outreach: Generic CCM calls that miss podiatry-specific questions reduce impact.
• Weak feedback loops: Without prompt communication back to podiatry, early issues may be overlooked.

The solution is to use shared documentation, podiatry‑informed scripts, and closed‑loop communication/referrals to ensure podiatric issues are surfaced and addressed promptly and aligned with systemic care goals, while maintaining CCM documentation standards.

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Compliance and Audit Readiness

Because DPMs can’t bill CCM, the supervising billing practitioner is responsible for: documented consent, current shareable e‑care plan, accurate monthly time logs, and ensuring services match CCM definitions. Podiatric findings should be integrated into the CCM record so the audit trail reflects whole‑patient management. Lara Health helps simplifying eligibility identification, embeds CCM workflows (consent prompts, podiatry‑aware scripts, care‑plan templates), tracks time by code, and streamlines closed‑loop referrals—helping teams stay both outcome‑focused and audit‑ready. Learn more about how Lara Health works.

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FAQs

Can podiatrists bill CCM directly?

No. CMS lists podiatrists among limited‑license practitioners not eligible to furnish/bill CCM. Billing must be done by an eligible MD/DO, NP, PA, CNS, or CNM.

Which podiatric conditions fit into CCM?

Peripheral neuropathy, PAD, recurrent ulcers, Charcot foot, and deformities threatening skin integrity—typically alongside another qualifying chronic condition (e.g., diabetes, CKD, hypertension).

How often should foot health be addressed in CCM?

At least monthly, with targeted questions and care‑plan updates; escalate any red flags to in‑person podiatry/vascular/wound care.

Does CCM replace podiatry visits?

No. CCM complements podiatry by coordinating monitoring and follow‑up between office visits.

Why is diabetes linkage so important?

Diabetes drives neuropathy and PAD, increasing ulcer and amputation risk; CDC data show large national burdens of amputations among people with diabetes. Monthly CCM helps operationalize prevention.

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References

CMS — MLN909188 Chronic Care Management Services (Booklet). 2025

ADA — Standards of Care in Diabetes—2024: Foot Care

CMS — Chronic Care Management FAQs (one billing practitioner per month)

IWGDF — Guidelines on the Prevention of Foot Ulcers in Persons with Diabetes (2023)

CDC — Preventing Diabetes‑Related Amputations (2024)

CDC — National Diabetes Statistics: Lower‑Extremity Amputations (2024)

Armstrong DG, et al. Diabetic Foot Ulcers: A Review. 2023