Obesity Rates are Rising – Are Your RAF Scores?
The landscape of obesity in the United States is changing rapidly—and not for the better. Since 2018, the number of states with adult obesity prevalence rates of 35% or higher has nearly doubled. This trend doesn’t just raise public health concerns—it has important implications for Medicare risk adjustment coding, particularly in identifying and documenting Morbid Obesity.
Obesity on the Rise: Updated Statistics
According to the latest data from the Centers for Disease Control and Prevention (CDC), 22 states reported an adult obesity prevalence of 35% or more in 2022—a stark increase from just 9 states in 2018. States like Texas, Iowa, Ohio, and Delaware joined the growing list in recent years, reflecting a widespread and accelerating public health challenge.
This upward trajectory in obesity rates correlates with increasing rates of chronic conditions such as type 2 diabetes, cardiovascular disease, and some forms of cancer. As obesity prevalence climbs, it's likely that the number of patients who meet the criteria for Morbid Obesity under CMS risk adjustment guidelines will also grow.
Source: https://www.healio.com/news/primary-care/20231004/cdc-finds-22-states-had-an-adult-obesity-prevalence-of-35-or-higher-in-2022
CMS Coding Criteria: What Qualifies as Morbid Obesity?
From a Medicare Advantage (MA) perspective, not every patient with a high body weight qualifies for risk adjustment under the Morbid Obesity category. CMS has specific documentation and diagnostic criteria for ICD-10 coding that must be met.
To capture Morbid Obesity for risk adjustment purposes, the following conditions apply:
A BMI ≥ 40 qualifies the patient outright.
A BMI between 35 and 39.9, plus one or more obesity-related comorbidities (such as hypertension, type 2 diabetes, or sleep apnea), also qualifies.
These diagnoses must be clearly documented during a face-to-face visit and supported by clinical evidence. Coders should take care not to assume a diagnosis based on BMI alone—appropriate comorbid conditions must be present and explicitly noted in the provider’s documentation.
The Clinical Toll: Comorbidities and Health Risks
Obesity is far more than a number on a scale. It is associated with a wide array of health complications that are both costly and difficult to manage. Adults with obesity face a significantly increased risk for:
Heart disease
Stroke
Type 2 diabetes
Certain types of cancer (e.g., endometrial, breast, and colon)
Mental health issues, including depression and anxiety
As these conditions often drive healthcare utilization and costs, accurate documentation becomes essential not just for reimbursement, but for care planning and population health management.
Disparities in Obesity Rates by Race and Ethnicity
The Behavioral Risk Factor Surveillance System (BRFSS) data from 2018 to 2020 highlights stark racial and ethnic disparities in obesity prevalence. While no states reported a 35% or higher obesity prevalence among non-Hispanic Asians, the numbers were considerably higher in other demographic groups:
7 states reported ≥35% obesity prevalence among non-Hispanic whites
22 states among Hispanics
35 states (plus D.C.) among non-Hispanic Blacks
These disparities are the result of a complex interplay of social determinants of health, access to care, nutrition, economic stability, and structural inequities.
COVID-19 and Worsening Inequities
The COVID-19 pandemic amplified these pre-existing health disparities. Black and Hispanic populations—already at higher risk for obesity—faced disproportionate impacts due to increased rates of chronic illness, reduced access to healthcare, and greater exposure to social risk factors. Obesity, in turn, contributed to more severe COVID-19 outcomes among these groups, further compounding the public health crisis.
What This Means for Providers and Coders
With obesity rates rising and CMS continuing to scrutinize risk adjustment data through mechanisms like RADV audits, it’s more important than ever for providers to ensure documentation is clear, compliant, and complete. Coders should look for:
Explicit documentation of BMI values
Notation of qualifying comorbidities when BMI falls between 35 and 39.9
Direct provider attribution of Morbid Obesity (not just inferred from vitals)
Accurate risk adjustment coding not only supports proper reimbursement but reflects the true clinical burden of your patient population—informing quality measures, care coordination, and value-based payment success.
As the national obesity epidemic continues to evolve, so too must our approach to documentation and coding. Identifying Morbid Obesity within the context of CMS risk adjustment is not just a coding issue—it’s a clinical imperative that supports better outcomes for some of our most vulnerable patients.
At ForeSee Medical, we noticed our clients were missing opportunities to document Morbid Obesity, this of course negatively impacted their RAF score prior to the use of the ForeSee Medical platform. To assure your providers are detecting Morbid Obesity we invite you to try our HCC risk adjustment coding software to help you discover patients with BMI greater than 35 and less than 40, plus documentation of a co-existing comorbid condition(s).
Remember, just listing a BMI value is not the best practice – take the time to document that you have discussed the Morbid Obesity diagnosis with the patient and your treatment plan.
Blog by: The ForeSee Medical Team