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Minnesota Department of Human Services Provider Manual
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Revised: 10-08-2018

  • Overview
  • Eligible Providers
  • Eligible Recipients
  • Covered Services
  • Noncovered Services
  • Authorization
  • Billing
  • Overview

    Spirometers are Pulmonary Function Tests used to measure the volume/flow of inhaled and exhaled air.

    Eligible Providers

    The following providers may provide spirometers:

  • • Federally Qualified Health Center
  • • Home health agencies
  • • Indian Health Services
  • • Medical suppliers
  • • Pharmacies
  • • Rural Health Clinic
  • TPL and Medicare

    Providers must meet any provider criteria, including accreditation, for third party insurance or Medicare. This is to help members for whom MHCP is not the primary payer.

    Eligible Recipients

    Spirometers are covered for MHCP members when medically necessary for home monitoring of respiratory or cardiovascular conditions.

    Covered Services

    Codes: A9284 (non-electronic), E0487 (electronic)

    Only spirometers approved by the Food and Drug Administration (FDA) are covered. Do not use A9284 or E0487 for incentive spirometers.


  • Authorization is required when the cost of the spirometer is over $400. . All authorization requests must include:
  • • Respiratory or cardiovascular condition Statement detailing medical need for home monitoring, including specific patient orders
  • • If electronic spirometer is requested, explain why a nonelectronic spirometer will not meet the member’s needs
  • Submit authorization request and required documentation to the authorization medical review agent.


    When billing with an approved authorization:

  • • Use MN–ITS 837P Professional
  • • Refer to the MN–ITS User Guide for DME, Medical Supplies, Prosthetic and Orthotic Services for detailed instructions.
  • • Enter the ordering provider in the Other Provider Types section of the Provider tab of the MN–ITS Interactive Claim
  • • Use the correct HCPCS code and the modifier NU or RR as noted on the authorization
  • Refer to the Billing section on the main Equipment & Supplies page and the Detailed Written Orders section for additional information.

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    © 2019 Minnesota Department of Human Services Updated: 10/8/18 10:28 AM | Accessibility | Terms/Policy | Contact DHS | Top of Page | Updated: 10/8/18 10:28 AM