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(at)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//