UNCLASSIFIED
ROUTINE
R 242121Z AUG 16
FM CNO WASHINGTON DC
TO NAVADMIN
BT
UNCLAS
NAVADMIN 187/16
SUBJ/CORRECTED COPY GUIDANCE FOR SEPARATION HISTORY AND PHYSICAL EXAMINATION
(SHPE) FOR DEPARTMENT OF NAVY (DON) ACTIVE/RESERVE COMPONENT SERVICE
MEMBERS//
MSGID/GENADMIN/CNO WASHINGTON DC//DNS/APR// GUIDANCE FOR SEPARATION HISTORY
AND PHYSICAL EXAMINATION (SHPE)//
REF/A/DOC/DOD/ DOD INSTRUCTION 6040.46, THE SEPARATION HISTORY AND PHYSICAL
EXAMINATION (SHPE) FOR THE DOD SEPARATION HEALTH ASSESSMENT (SHA) PROGRAM
REF/B/DOC/MANUAL OF THE MEDICAL DEPARTMENT, CHAPTER 15
REF/C/DOC/MANUAL OF THE MEDICAL DEPARTMENT, CHAPTER 16
REF/D/DOC/MANUAL OF THE MEDICAL DEPARTMENT, CHAPTER 18
REF/E/DOC/DEPARTMENT OF THE NAVY (DON) DISABILITY EVALUATION MANUAL
REF/F/DOC/001/15 DON ALNAV GUIDANCE FOR SEPARATION HISTORY AND PHYSICAL
EXAMINATION FOR ALL DEPARTMENT OF NAVY ACTIVE/SELECTED RESERVE SERVICE MEMBER
REF/G/DOC/NAVADMIN 187/14, PROPER TRANSFER OF HEALTH SERVICE TREATMENT
RECORDS (STRS) OF TRANSITIONING SERVICE MEMBERS TO THE VETERANS
ADMINISTRATION
RMKS/1. This NAVADMIN outlines proper guidance for the Separation History
and Physical Examination (SHPE) program in accordance with references (a)
through (g). All Commanders, Commanding Officers, and Officers-In-Charge
shall ensure compliance with the requirements contained herein regarding SHPE
responsibilities, procedures, and information collection requirements for all
Sailors, to include Reserve Component (RC) members.
2. Background. It is of paramount importance to ensure that Service Members
receive an accurate and valid SHPE while having an orderly transition to
civilian life. This NAVADMIN serves to provide guidance on SHPE processes,
for the purpose of applicability, requirements, components, timing, and
coding of SHPE, as the SHPE is the objective basis for any Department of
Veterans Affairs (VA) benefits claims made by the Service member after
separation.
3. Applicability. All members of the Navy preparing for release from active
duty must complete a comprehensive SHPE prior to their scheduled date of
release. This also applies to RC members in an active duty status for 180
days or more, RC members separating after 180 days or more of continuous
service on active duty orders, or RC members separating with 30 days or more
of continuous service on active duty orders in support of a Contingency
Operation.
4. Meeting the requirements:
a. Service Members will not require a SHPE if they are separating or
retiring after being found unfit for continued military service through the
disability evaluation process and have completed the examinations in that
process.
b. As stated in reference (a), any examination completed by the following
means and within the required time period is sufficient: completion of DD
Form 2807-1 and DD Form 2808, a termination audiogram completed within the
previous 6 months on DD Form 2216, laboratory testing, occupational health
termination examinations, or other examinations performed for any other
reason that meets the components of the SHPE is sufficient. The exam must be
properly documented within the Armed Forces Health Longitudinal Technology
Application (AHLTA). If AHLTA is not available, the SHPE is documented on
paper and filed in the members Service Treatment Record (STR).
c. When a medical assessment is used to update a previous medical history
and physical examination completed on DD Form 2807-1 and DD Form 2808 or
electronic medical record equivalent, and a condition not previously
documented is discovered, the credentialed examining provider will evaluate
the complaint objectively within the scope of a screening physical
examination. Any serious, potentially unfitting condition found requires a
new SHPE to be completed and referral for further evaluation and treatment of
the new condition, as may be clinically indicated.
5. Components of SHPE. Prior to separation, each Service Member must
receive a SHPE as documented on DD Form 2807-1 and DD Form 2808. Components
include:
a. DD Form 2807-1, completed by Service Member, with comments on all
positive responses completed by the credentialed provider performing the
SHPE. The provider will document if the Sailor is qualified (or suitable)
for separation/retirement; or, if the Sailor is unqualified (unsuitable) for
separation/retirement and referred into the Integrated Disability Evaluation
System (IDES). The majority of Sailors who are retiring will be presumed
fit.
b. DD Form 2808, completed by a credentialed provider and a review of
medical record (hard-copy and electronic) and record of significant medical
conditions.
c. Threshold/termination audiogram with complete audiology evaluation if
the threshold/termination audiogram indicates a significant threshold shift
after the second follow-up test.
d. Optional Hepatitis C testing per U.S. Centers for Disease Control
guidelines.
e. All occupational health termination examinations required by
Department of Defense (DOD) policy (e.g., hearing conservation, radiation,
asbestos medical surveillance), to include any periodic testing required by
other issuances
(e.g., HIV testing), must be completed before SHPE is conducted.
f. All SHPE documentation be uploaded in AHLTA when possible and be
included with the Service Members STR.
g. The examining health care provider must have verified credentials
deemed appropriate by the Military Treatment Facility (MTF) privileging
authority to perform such examinations as a physician, physician’s assistant,
or nurse practitioner. For exams performed by contracted providers though
the Reserve Health Readiness Program, the providers credentials must be
verified according to the terms of the contract. An Independent Duty
Corpsman (IDC) does not have the verified credentials deemed appropriate to
conduct these examinations.
6. Timing of SHPE:
a. A SHPE performed up to 30 days prior to the date of separation from
active duty requires no further documentation.
b. A SHPE performed up to 90 days prior to the date of separation from
active duty must be validated as current not more than 30 days prior to the
date of separation. Validation is an administrative requirement, but it must
contain a separate entry by a credentialed provider and transcribed into the
STR for tracking purposes.
c. A DOD-performed physical examination may be accepted between 90 days
and up to 12 months prior to the scheduled date of separation if it meets
SHPE minimum standards, but must still be validated by a credentialed
provider as current not more than 30 days prior to the date of separation.
d. A SHPE performed for Service Members at an OCONUS location with a
servicing MTF must be conducted at the respective OCONUS MTF. For
Service Members in remote duty CONUS/OCONUS locations that do not have a
servicing MTF, the SHPE will be conducted at a CONUS fleet concentration area
servicing MTF prior to separation out-processing.
e. When a Service Member has terminal leave, the final out-processing
date may be used in lieu of date of separation from active duty for timeline
requirements.
f. Per ref (c), the STR is the property of the U.S. Government and must
be maintained by the medical department which has primary cognizance over the
care of the patient. Proper archiving of STRs (medical and dental records)
is essential for effective processing of Service member Department of
Veterans Affairs (VA) benefit claims. Failure to maintain STRs with the
Sailors and Marines medical/dental department will likely affect or delay
future benefits upon the members separation/retirement. All unit Commanders,
Commanding Officers, and Officers-In-Charge will ensure 100 percent of their
Service Members have submitted their STR to their supporting medical/dental
department prior to the Service Members final out-processing date.
g. All medical/dental departments shall have positive control of the
Service Members STR prior to the SHPE being validated as current 30 days or
less prior to any out-processing date.
h. Per ref (g), a reasonable search to locate and retrieve the STR must
be conducted. If prior duty stations are unknown, the responsible Navy
medical and dental records department shall contact NPC Customer Service
Center (1-866-827-5672/DSN: 882-5672, email: uasknpc@navy.mil). For any
medical/dental department that does not have a Service Members STR when
validating SHPE current 30 days or less prior to any out-processing date, the
responsible medical/dental department must document its reasonable search
efforts with NPC Customer Service Center and the Service Member in DD Form
2963 Block 4, per reference (g).
7. Coding of SHPE:
a. All Medical Departments conducting the SHPE must utilize the ICD-10-CM
DoD Unique Code Diagnosis DOD0222 "Separation/Termination/Retirement
Examination: Examination performed at the end of employment and for
retirement or separation" as the documented primary diagnosis. No other ICD-
10-CM Diagnosis DoD Unique Code is authorized, with the exception of
operational commands that have not had the technical refresh, or have not yet
been authorized by higher authority to convert to ICD-10-CM. In these cases
commands will use the ICD-9-CM Diagnosis V-Code, V70.5_9,
Separation/Termination/Retirement Exam: Examination performed at the end of
employment and for retirement or separation must be utilized as the
documented primary diagnosis. No other ICD-9-CM Diagnosis V-Code is
authorized for SHPE documentation by these commands that have not converted
to ICD-10-CM.
b. All ICD-10-CM DoD Unique Code Diagnosis DOD0222 coded SHPEs must be
accompanied by Current Procedural Terminology (CPT) procedure code 99420 for
the administrative and review process. The ICD-10-CM Diagnosis DoD Unique
Code, DOD0222, will not be utilized for any other documentation purposes.
8. Reporting Requirements:
a. Commanders, Commanding Officers and Officers-In-Charge of Military
Treatment Facilities, and Department Heads of Operational Medical
Departments, shall report the status of each separating/retiring Service
members SHPE in the Navy’s SHPE tracking system, as it is implemented in
their command. Commands which do not have organic medical assets will rely on
the MTF or Branch Health Clinic performing their Service members SHPE.
b. Bureau of Medicine and Surgery (BUMED). On a quarterly basis, shall
provide the consolidated information to Assistant Secretary of the Navy
(Manpower and Reserve Affairs)(ASN M&RA).
c. All commands will advise their qualifying Service Members at least 180
days prior to their separation that they need to complete a SHPE. This
advisement will occur on NAVPERS 1070/13 Administrative Remarks. Attendance
at the Transition Assistance Program (TAP) and subsequent Transition: GPS
(Goals, Plans, and Success) modular curriculum is not a substitute for the
notification process.
9. Unit Commanders and Officers-In-Charge are directed to take all
appropriate actions to identify SHPE processing issues well in advance of the
separation of Service Members and coordinate as necessary with their
respective chains of command, Bureau of Naval Personnel, and BUMED to ensure
the requirements of this NAVADMIN are met.
a. Command separation check-out sheets shall be modified to reflect the
requirement to complete a SHPE prior to actual separation/end of active
obligated service. The medical department will annotate compliance.
b. Temporary duty and terminal leave may be held in abeyance as deemed
necessary to facilitate completion of SHPE process prior to separation of a
Service Member.
C. Service Members may not be retained on active duty beyond the
expiration of their active duty service obligation unless specifically
provided for by applicable law and policy.
10. Released by Vice Admiral R. L. Thomas, Director, Navy Staff//
BT
#0001
NNNN
UNCLASSIFIED//