A4376 — Ostomy pouch, drainable, with faceplate attached, rubber, each
HCPCS Level II A-code · short descriptor: “Drainable rubber pch w fcplt”
- Code system
- HCPCS Level II
- Family
- A — Medical & surgical supplies, ambulance
- Medicare coverage status
- Special coverage instructions apply
- DMEPOS payment category
- Ostomy, tracheostomy & urological supplies
- Prior authorization
- Not on Medicare required-PA list
- Face-to-face & WOPD
- Not on the required list
- Status
- Active (April 2026 HCPCS)
Prior authorization
Not on the Medicare required-PA list as of the January 13, 2026 update (74 items). Medicare Advantage and commercial plans set their own prior-authorization rules for this code — verify per plan before delivery.
Order readiness — what the written order must contain
Every Medicare DMEPOS claim needs a Standard Written Order with all six elements (42 CFR 410.38(d)):
- Beneficiary name or Medicare Beneficiary Identifier (MBI) (42 CFR 410.38(d)(1)(i)(A))
- General description of the item (42 CFR 410.38(d)(1)(i)(B))
- Quantity to be dispensed, if applicable (42 CFR 410.38(d)(1)(i)(C))
- Order date (42 CFR 410.38(d)(1)(i)(D))
- Treating practitioner name or NPI (42 CFR 410.38(d)(1)(i)(E))
- Treating practitioner signature (42 CFR 410.38(d)(1)(i)(F))
Not on the F2F/WOPD list (April 13, 2026 update — 83 items). The standard written order must reach the supplier before claim submission.
Blank requirements checklist only — MyMedi-AI never collects or stores completed orders.
A4376 Medicare fee schedule (April 2026)
Base (no modifier) Ostomy, tracheostomy & urological supplies
Medicare allowable ranges from $67.81 to $74.60 depending on state and rural status.
Former-CBA payment limits: ceiling $67.81 · floor $57.64
| State | Non-rural | Rural |
|---|---|---|
| AK | $68.47 | — |
| AL | $67.81 | — |
| AR | $67.81 | — |
| AZ | $67.81 | — |
| CA | $67.81 | — |
| CO | $67.81 | — |
| CT | $67.81 | — |
| DC | $67.81 | — |
| DE | $67.81 | — |
| FL | $67.81 | — |
| GA | $67.81 | — |
| HI | $73.24 | — |
| IA | $67.81 | — |
| ID | $67.81 | — |
| IL | $67.81 | — |
| IN | $67.81 | — |
| KS | $67.81 | — |
| KY | $67.81 | — |
| LA | $67.81 | — |
| MA | $67.81 | — |
| MD | $67.81 | — |
| ME | $67.81 | — |
| MI | $67.81 | — |
| MN | $67.81 | — |
| MO | $67.81 | — |
| MS | $67.81 | — |
| MT | $67.81 | — |
| NC | $67.81 | — |
| ND | $67.81 | — |
| NE | $67.81 | — |
| NH | $67.81 | — |
| NJ | $67.81 | — |
| NM | $67.81 | — |
| NV | $67.81 | — |
| NY | $67.81 | — |
| OH | $67.81 | — |
| OK | $67.81 | — |
| OR | $67.81 | — |
| PA | $67.81 | — |
| PR | $74.60 | — |
| RI | $67.81 | — |
| SC | $67.81 | — |
| SD | $67.81 | — |
| TN | $67.81 | — |
| TX | $67.81 | — |
| UT | $67.81 | — |
| VA | $67.81 | — |
| VI | $67.81 | — |
| VT | $67.81 | — |
| WA | $67.81 | — |
| WI | $67.81 | — |
| WV | $67.81 | — |
| WY | $67.81 | — |
Common denial codes to watch
Related A-codes
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