This might be helpful....
NUMBER OF DIAGNOSES OR MANAGEMENT OPTIONS
The number of possible diagnoses and/or the number of management options that must
be considered is based on the number and types of problems addressed during the
encounter, the complexity of establishing a diagnosis and the management decisions
that are made by the physician.
Generally, decision making with respect to a diagnosed problem is easier than that for
an identified but undiagnosed problem. The number and type of diagnostic tests
employed may be an indicator of the number of possible diagnoses. Problems which
are improving or resolving are less complex than those which are worsening or failing
to change as expected. The need to seek advice from others is another indicator of
complexity of diagnostic or management problems.
DG: For each encounter, an assessment, clinical impression, or diagnosis
should be documented. It may be explicitly stated or implied in
documented decisions regarding management plans and/or further
evaluation.
• For a presenting problem with an established diagnosis the record should
reflect whether the problem is: a) improved, well controlled, resolving or
resolved; or, b) inadequately controlled, worsening, or failing to change as
expected.
• For a presenting problem without an established diagnosis, the
assessment or clinical impression may be stated in the form of differential
diagnoses or as a "possible", "probable", or "rule out" (R/O) diagnosis.
DG: The initiation of, or changes in, treatment should be documented.
Treatment includes a wide range of management options including patient
instructions, nursing instructions, therapies, and medications.
DG: If referrals are made, consultations requested or advice sought, the record
should indicate to whom or where the referral
Documentation Guidelines for Evaluation and Management (E/M) Services
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/EMDOC.html
Official CMS Information for Medicare Fee-for-Service Providers Evaluation & Management Guide
http://www.cms.gov/Outreach-and-Edu.../Downloads/eval_mgmt_serv_guide-ICN006764.pdf