Spa Salt

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Sun Tan Lotion

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Hand Care Center ("HCC")

In the case of The Hand Care Center (November 20, 2003) CASE | DECISION | JUDGES | FOOTNOTES Department of Health and Human Services DEPARTMENTAL APPEALS BOARD Medicare Appeals Council IN THE CASE OF Claim For (Appellant) (Beneficiary) (HICN) (Carrier) (Docket Number) DECISION ...TO TOP On October 29, 2002, the Medicare Appeals Council advised The Hand Care Center ("HCC") that it had decided, on its own motion, to review the Administrative Law Judge's August 30, 2002 decision in this case. Because that decision contains an error of law, the Council hereby reverses the August 30, 2002 decision and finds that Medicare payment may not be made for the services at issue. In deciding to review the August 30, 2002 decision, we considered the record that was before the Administrative Law Judge, as well as the October 25, 2002 memorandum (with attachments) from the Centers for Medicare & Medicaid Services (CMS). The CMS memorandum is hereby entered into the record in this case as Exhibit AC-1. In addition, we considered correspondence -- dated September 30 and November 18, 2002 -- filed by HCC in response to our notice of own motion review and proposed decision in another case ( S.J.C., et al. , Docket Numbers 999-19-0242 et al.) that addresses issues identical to those in this case. (1) HCC's November 18, 2002 correspondence consisted of a letter (with attachments) from Julio Taleisnik, M.D. Finally, we considered Dr. Taleisnik's February 28, 2003 letter in response to our Notice of Own Motion Review and Proposed Decision in this case. The beneficiary underwent hand surgery on March 2, 2000. (Exh. 3 at 1). The surgery was performed by a primary surgeon and an assistant surgeon. ( Id .). HCC billed Medicare for the surgery under the following HCPCS codes: 25810 (arthrodesis, wrist; with iliac or other autograft); 25248 (exploration with removal of deep foreign body, forearm or wrist); 64721 (neuroplasty and/or transposition; median nerve at carpal tunnel), and 25116 (radical excision of bursa, synovia of wrist, or forearm tendon sheaths; extensors, with or without transposition of dorsal retinaculum). In addition to seeking payment for the services of the primary surgeon, HCC requested payment for the services of the assistant surgeon (also known as an "assistant-at-surgery") by appending modifier "-80" to each of these codes. With respect to HCPCS code 25810, the carrier allowed payment for both the primary and assistant surgeon's services. The carrier (or its hearing officer) also authorized payment for the primary surgeon's services under HCPCS codes 25248 and 64721. However, it denied payment for the assistant surgeon's services under procedure codes 25248 and 64721. In addition, the carrier determined that no payment could be made (for either the primary or assistant surgeon's services) under HCPCS code 25116 because it was a component of (i.e., "bundled" with) the procedure designated by HCPCS code 25810. Thus, there are two issues before us: first, whether payment can be made the services of an assistant-at-surgery under HCPCS codes 25248 and 64721; and second, whether payment can be made for the services billed under HCPCS code 25116. As explained below, we find that no additional payment may be made under these codes. Issue 1: Whether payment can be made for the assistant-at-surgery services billed under HCPCS codes 25248 and 64721. Medicare's denial of payment for the assistant surgeon's services was based on section 1848(i)(2)(B) of the Social Security Act (Act), (2) which provides: If the Secretary determines, based on the most recent data available, that for a surgical procedure (or class of surgical procedures) the national average percentage of such procedure performed under this part which involve the use of a physician as an assistant at surgery is less than 5 percent, no payment may be made under this part for services of an assistant at surgery involved in the procedure. Based on consultations with the medical community and nationwide utilization data, CMS has identified the procedures that involve the services of assistants-at-surgery in less than five percent of cases nationally. See 56 Fed. Reg. 59502, 59603-04 (Nov. 25, 1991); 57 Fed. Reg. 36006, 36008 (Aug. 12, 1992). These CMS determinations are listed in the Medicare Physician Fee Schedule Database (MPFSDB). See Medicare Carriers Manual 4828(D) & 15900.1. For each procedure listed in the MPFSDB, there are several fields that designate, among other things, Medicare's payment policies with respect to the procedure. If the numeric indicator in the "assistant surgeon" field (field 23) is 1, then the procedure is subject to the statutory payment limitation in section 1848(i)(2)(B), and no payment may be made for an assistant-at-surgery. Id . 15900.1. For each of the above-listed procedures, the numeric indicator in field 23 of the MPFSDB is "1". ( See Exh. AC-2, attached to this decision). These procedures are therefore subject to the statutory prohibition on payment for the services of an assistant-at-surgery. The Administrative Law Judge determined that applying section 1848(i)(2)(B) of the Act was inappropriate here because the procedures in question are performed mostly in teaching hospitals, using residents as surgical assistants, and thus are not reflected in the national utilization statistics for assistants-at-surgery. However, the file contains no data or other evidence (except for the assertion of a HCC employee) that these procedures are performed mostly in teaching hospitals. In addition, we note that, in the preamble to the final rule implementing section 1848(i)(2)(B) of the Act, CMS rejected a recommendation that the services of teaching hospital residents be counted in determining whether a procedure is subject to the payment limitation, saying: We do not believe Congress intended to count interns and residents as physicians for purposes of the 5 percent threshold. Moreover, we would note that section 4107 of OBRA '90 [which enacted the statutory payment limitation] states that no payment may be made under part B for services of an assistant-at-surgery when the national average percentage of such procedures "performed under this part" involving the use of a physician as an assistant-at-surgery is less than 5 percent. The phrase "under this part" refers to part B. Since the services of interns and residents are almost always part A services and are not part B physicians' services, they would not be counted for purposes of the assistants-at-surgery provision in most cases. We would modify our list of services if data were presented to show that interns and/or residents provide assistant-at-surgery services on an outpatient (part B) basis and would increase the percent to 5 percent or more nationally. 57 Fed. Reg. 36006, 36008 (August 12, 1992). We find nothing in the statute, legislative history, regulations, or agency policy statements that is inconsistent with CMS's interpretation of section 1848(i)(2)(B), or with its reasons for not counting the assistant-at-surgery services performed by teaching hospital residents in determining whether a particular procedure is performed more than five percent of the time. As indicated, Medicare has determined that the statutory payment limitation in section 1848(i)(2)(B) is applicable to each of the codes at issue. In an apparent attempt to challenge the limitation's applicability, HCC submitted (as attachments to Dr. Taleisnik's November 18, 2002 letter) excerpts from a report entitled Physicians as Assistants at Surgery. The report contains the results of a study performed by the American College of Surgeons and 15 specialty organizations concerning the need for a physician as an assistant-at-surgery for all procedures listed in the "Surgery" section of the American Medical Association's Current Procedural Terminology. Each participating organization was asked to review codes applicable to their specialty and determine whether the operation requires the use of a physician as an assistant-at-surgery: (1) almost always, (2) almost never; or (3) some of the time. However, no numerical values were assigned to these categories. Moreover, the study does not purport to reflect actual nationwide utilization rates. Under the circumstances, we do not have sufficient grounds to disturb the Medicare program's determination that, for the procedures in question, an assistant-at-surgery is used in less than five percent of outpatient cases nationwide. Dr. Taleisnik asserts that the care rendered by the assistants-at-surgery in this case was medically necessary and appropriate, and that the "decision making of a Surgeon, who has all the facts when determining to use an Assistant at Surgery, cannot be ignored." However, as we indicated in our November 8, 2002 letter to HCC, medical necessity is not an issue in this case. The issue is the applicability of a statutory payment limitation and, more specifically, Medicare's determination that the services of assistants-at-surgery are, for the procedures in question, used in less than five percent of cases nationally. For procedures in which an assistant-at-surgery is used less than five percent of the time, Congress has directed the Medicare program not to pay for the services of the assistant surgeon, regardless of whether the services are medically necessary. Neither the Medicare program nor the Medicare Appeals Council has the legal authority to ignore this statutory limitation when it applies (as it does here). Issue 2: Whether separate payment can be made for services billed under HCPCS code 25116. Section 1848 of the Social Security Act authorizes the Medicare program to establish a fee schedule that sets payment amounts for physician services. Pursuant to that statutory authority, Medicare has established uniform national policies to implement the fee schedule, including a requirement that physicians utilize the HCFA Common Procedures Coding System (HCPCS) when billing for services provided to Medicare beneficiaries. See 42 C.F.R. 414.40. With respect to a physician's surgical services, a key national policy is that "[a]ll services integral to accomplishing a procedure are considered bundled into that procedure and, therefore, are considered a component part of the comprehensive [HCPCS] code." ( See Medicare Carriers Manual (MCM) 15068(A)). These "integral" services are assumed to represent the standard of care in accomplishing the comprehensive procedure, and accordingly payment for them is bundled into the payment for the comprehensive procedure. ( Id . 4630(F), 4824(A) 15010 & 15068). In 1996, the Health Care Financing Administration (now known as the Centers for Medicare and Medicaid Services) implemented a national "Correct Coding Initiative" (CCI), the aim of which was to clarify or develop national coding and payment policies and to promote and ensure accurate billing by physicians. ( See MCM 4630). The CCI established the following principles for determining when payment for a component service is included in the payment for a more comprehensive procedure: The service represents the standard of care in accomplishing the overall procedure; The service is necessary to successfully accomplish the comprehensive procedure; failure to perform the service may compromise the success of the procedure The service does not represent a separately identifiable procedure unrelated to the comprehensive procedure performed. (MCM 15068(A)). As part of the CCI, HCFA published the National Correct Coding Policy Manual (NCCPM), which identifies "comprehensive" and "component" codes for surgical services. Comprehensive codes relate to procedures that may include multiple services which, when performed together, should be billed only under that code. NCCPM 5.2 (July 1999), Chapt. 1, Part K. Component codes identify procedures that can be billed separately when performed separately, but when performed as part of a comprehensive procedure should be billed only under the comprehensive code. Id . The NCCPM identifies HCPCS code 25116 as a component of HCPCS code 25810 (arthrodesis, wrist; with iliac or other autograft). ( See NCCPM 5.2 (1999)). According to the policy statement associated with this pair of codes, the service designated by HCPCS code 25116 is integral to accomplishing the procedure designated by HCPCS code 25810 under accepted standards of medical and surgical practice. Consequently, the service designated by HCPCS code 25116 is considered to be bundled with the comprehensive procedure (HCPCS code 25810) and is generally not separately payable. ( Id . Chapt. 1, Part B). Under billing modifier -59, Medicare permits separate payment to be made for an otherwise bundled service if it constitutes a distinct and independent service unrelated to the other services performed on the same day. See MCM 4630(D)(4). As noted, the CCI indicates that a synovectomy (CPT code 25116) is, under accepted standards of surgical practice, performed as a necessary or integral component of the fusion procedure described in CPT code 25810. Consequently, separate payment may be made under modifier -59 only if the synovectomy constitutes a distinct and independent procedure unrelated or not integral or necessary to the successful completion of the fusion. This issue was not addressed by Dr. Taleisnik, the beneficiary's surgeon, in his correspondence with the Council. In particular, he did not assert that the synovectomy was not essential or integral to accomplishing the fusion. Nor did he show that accepted standards of surgical practice required that the synovectomy be considered a separately payable procedure, rather than a component of the fusion, in view of the beneficiary's condition. We therefore cannot find that HCC is entitled to separate payment for the synovectomy under modifier -59. In his February 28, 2003 letter, Dr. Taleisnik asserted that CPT code 25810 was intended to report a wrist fusion procedure for patients with posttraumatic changes, and not for fusions performed on patients, like the beneficiary, who have rheumatoid arthritis or other inflammatory synovitis. Dr. Taleisnik also asserted that fusions performed on patients with rheumatoid arthritis and synovitis are typically more complex and time consuming. We accept this assertion as true but note that HCC's payment for the fusion reflected the added time and complexity because CPT code 25810 was billed with modifier -22. ( See Exh. 1). Modifier -22 is properly used when a procedure involves greater than normal complexity or other unusual circumstances. MCM 4822(A)(10) and 15028. Decision Based on the analysis above, the Medicare Appeals Council finds that no payment may be made under Medicare Part B for (1) the services of an assistant-at-surgery under HCPCS codes 25248 and 64721, or (2) the services billed under HCPCS code 25116. Date: July 1, 2003 JUDGE S ...TO TOP Thomas E. Herrmann Administrative Appeals Judge Bruce Gipe Administrative Appeals Judge FOOTNOTES ...TO TOP 1. In response to our notice of own motion review in the Chaplin case, HCC requested the opportunity to present oral argument. We denied the request in a November 8, 2002 letter. In a November 18, 2002 letter, HCC asked us to reconsider our decision to forego oral argument. We gave further consideration to the request but again concluded that oral argument was not necessary to help us reach a proper decision. Our reasons for denying oral argument apply to this case as well. 2. This provision is codified in the regulations at 42 CFR 411.15(n). CASE | DECISION | JUDGES | FOOTNOTES

SOAP 1.2 hopefullywill allow

REST + SOAP intertwingly It's just data REST + SOAP By Sam Ruby, July 20, 2002. Preface The introduction of the WebMethod Specification Feature in SOAP 1.2 hopefullywill allow the continuing REST vs SOAP debate to focus on thesubstantive differences between these two approaches. Thisessay captures what I consider to be the strengths of eachapproach, and outlines a path whereby one can "cherry pick" thebest features of each in designing an application. Rest vs RPC In reality, there aren't two sides. There are at leastfour. Everything is a resource Everything is a get Everything is a message Everything is a procedure Furthermore, everything doesn't fit into such neat littlebuckets. Anyway, each of these points of view are limiting insome way that their adherents are typically too blind to see. If all you have is a hammer, then everything looks like a nail, andall that. Telling these guys apart is sometimes difficult. Here's afew clues. Read them along the lines of a Jeff Foxworthy "you might be a redneck if..." You might be a Resource guy if you actually use HTTP PUT You might be a Get guy if you use URLs to request parameterizedactions You might be a Message guy if you actually use XMLattributes You might be a Procedure guy if you feel you must encode XML inorder to pass it as a parameter OK, So, I won't quit my day job. But the key points hereis that not all HTTP GETs are RESTful, nor are all SOAP callsRPC. Brief history of software engineering 1960s Every assembler instruction and data location was individuallyaddressable. Code and data areinterchangeable. 1970s Gotos are consideredharmful . Subroutines provided parameterized andcontrolled entry points. 1980s SQL and relational databases were introduced. All datacould be accessed and manipulated with insert, select, update, anddelete statements. 1990s Subnets were bridged by an "inter-net" protocol. Subroutines with parameters became objects with messages byvirtue of moving the first parameter outside of theparenthesis. Stored procedures became the norm for any operation thatmodifies relational databases. 2000s TCP/IP displaced the subnet protocols it was supposed tobridge HTML replaced "green screens" as the popular source for "screenscrapping" Service Oriented Architecture s and Application Level Inter Networking isintroduced. Several key points here. If your leanings are towardsREST, then contemplate the notion of stored procedures: why do mostmodern relational database systems support such a concept? What problem do stored procedures solve? If your leanings aretowards SOAP, get prepared for the object reference to move outsideof the parenthesis. Either way, realize that things youbelieve in strongly today may - nay will - get abstracted away inthe future. Resources vs Services From a protocol (i.e., what goes across the wire) perspective -what's the key difference? To put it in the most simplest ofterms, the difference is between what goes inside the envelope andwhat goes outside. When you mail a check to a credit cardcompany, do you put your account number inside or outside of theenvelope? This difference might seem a bit esoteric, but theobject oriented revolution can also be expressed in similarlysimple terms. An example of the difference is encoding - in other words,specifying the character set used. If you send XML over HTTP,there is a redundancy. XML provides for the specification of encoding ,as does HTTP . The fact is, when you have two places where a pieceof data can be represented, you open up the possibility ofconsistency problems. This exists in HTTP as HTTP is designedto be independent of the representation of the resource, and itexists in XML as encoding is not only relevant during transfer, butalso when it is locally transformed or stored. The most extreme difference between these two models is on thename of resource itself. In REST, the resource is identifiedoutside of the envelope a Uniform Resource Identifiers (URI). While SOAP doesn't preclude this possibility, most soap servicesdeployed today aren't designed in this fashion. This is notall bad. Once you realize that an architecture point of view,whether this service is accessed via GET or POST doesn't make itany more RESTful, you realize that Google is a service. Onewhich permits parameters to be encoded on the URL. Key point here: when designing for resilience in the face ofchanging requirements, it generally behooves one to make choicesthat preclude the least number of future alternatives. Inparticular, one needs to be prepared for the dynamic creation ofnew resources, parameterized requests, and obtaining theidentifiers of resources in responses. The Dark Matter of the Internet Cosmologists have long posited the existence of dark matterwhose sole purpose is to contribute enough inertia to stop theinfinite expansion of the universe. In physics, the way onegenerally makes observations is by bouncing a few photons off ofthe subject. For large bodies, the effect on the subject isminiscule and can largely be ignored. On the internet, the analogy to a photon would be a HTTPGET. Clay Shirkey wrote an excellent article referring to PC's as the dark matter of the internet, largelybecause, they as a general rule, don't respond to HTTP GET. Unfortunately, the same is true of virtually al SOAP 1.1services. While they may interact with one another usingalternate mechanisms over HTTP, they don't interact with HTTP GETmaking them all but inaccessible to a large number of clients. SOAP 1.2's WebMethod feature provides the means to shed some light on thissituation. In the words of the spec Applications SHOULD use GET as the value of webmeth:Method in conjunction with the 6.3 SOAPResponse Message Exchange Pattern to support informationretrievals which are safe, and for which no parameters other than aURI are required; I.e. when performing retrievals which areidempotent, known to be free of side effects, for which no SOAPrequest headers are required, and for which security considerationsdo not conflict with the possibility that cached results would beused. The key point here is that applications that desire to bebroadly accessible should be designed with this in mind - in otherwords, to maximize their visible surface area. Structural support I have the utmost respect for those individuals who developed theprotocols that became the backbone of the modern internet. However, I also have equal respect for those that built thenetworks that allow our financial institutions to securely transferfunds (e.g., CICS ). And for those that have developed OLTP databases that are capableof handing hundreds of thousands of transactions per second andterrabytes of data (for examples, see TPC ). It is worth noting that many web sites are updated usingmechanisms such as ftp and xcopy. So, while REST is clearlyTuring complete, its best known application (i.e., the internet),only clealy demonstrates its applicability and scalability tohighly read only and mostly public data. It is theexpression of higher level operations (particularly ones thatperform non-atomic updates) that SOAP's value proposition becomesapparent. Sometimes, one truly wants to have an atomic"transfer funds from savings to checking" transaction instead ofsimply a series of discrete GET and PUT's. And for all of it's greatness, REST does little to assure thatthe HTML I produce will render properly in the browser of yourchoice. That's simply left as an exercise for thestudent. That's where WSDL comes in. WSDL builds uponyour choice of schema languages (though XML Schema seems to havetake an early and apparently commanding lead at the moment) andadds the notion of a PortType: namely if my service gets a messageof a given shape, it will promise to return a message of a givendescription otherwise it will produce a fault. Finally one of the key success factors of the web is notdirectly related to REST at all, but instead to HTML. This isthe simple statement in the original HTMLInternet Draft that any undefined tags may be ignored byparsers. This lead the way to a predictable path of evolutionof the HTML standard where new content could remain backwardscompatible with older browsers. As I argue in Coping with Change and A Busy Developers Guide to WSDL 1.1 , these simple principlescan be applied to Web Services. However, as this rule is notreflected in (or precluded by, for that matter) the current SOAPspecifications, one unfortunately can not rely on all toolkits toimplement it. If one could, the rules for evolving a webservice would allow adding optional parts/elements with uniquequalified names (that's the combined namespace name plus the localname) to existing services. Ideally, such rules would permitthe inclusion of optional/ignorable/mandatory flags in the body, akin to the mustUnderstand attribute already permitted in the header. The key points here are that much of the value (in even fullyRESTful systems) is in the precise documentation of the structuresexpected in requests and responses. Unification It should be clear from the above that I believe it is quitepossible to productively apply both supposedly incompatibleapproaches together. I'll sketch it out below, inprescriptive form. Note: while this is proscriptive, it isexpected that local adaptations will be provided. Start by modeling the persistent resources that you wish toexpose. By persistent resources, I am referring to entitiesthat have a typical life expectancy of days or greater. Ensure that each instance has a unique URL. When possible,assign meaningful names to resources. Whenever possible, provide a default XML representation foreach representation. Unlike traditional object orientedprogramming languages where there is a unique getter per property,typically there will be a single representation of the entireinstance. These representations will often contain XLinks(a.k.a. pointers or references) to other instances. Now add high level methods which take care of all compositecreate, update, and delete operations. A key aspect of thedesign is that messages for these operations need to be selfcontained - both the sender and receiver should be able to make theabsolute minimum of assumptions as to the other's state, andmultiple requests should not be required to implement a singlelogical operation. All requests should provide the appearanceof being executed atomically. Query operations deserve special consideration. A generalpurpose XML syntax should be provided in every case. Inaddition, when a reasonable expectation exists that queryparameters will be of a relatively short size and not requiresignificant encoding, then a HTTP GET with the parameters encodedas a query string should also be provided. Implications The following table emphasizes how this unified approach differsfrom the "pure" (albeit hypothetical) different positions describedabove. Resource POST operations explicitly have the possibility of modifyingmultiple resources. PUT and DELETE operations are rarelyused, if ever. GETs may contain query arguments. Get GETs must never be used for operations which observably changethe state of the recipient. POST should be usedinstead. Message Do not presume that URLs are static, instead presume that theyidentify the resource. In particular, recognize thatURLs can be dynamically generated. Expect URLs of other SOAPResources in responses. Use the SOAP Response MEP for pureretrieval operations. Procedure Treat the URL itself as the implicit firstparameter. Allow URLs to be dynamically generated, andreturned in structures. Use HTTP GET for retrievaloperations. Conclusions Looking to the future, the application level inter -networking protocols that emerge today will likely bethe application level intra -networking protocols of the nextdecade. Both REST and SOAP contain features that the otherslack. Most significantly: REST - SOAP = XLink The key bit of functionality that SOAP applications miss todayis the ability to link together resources. SOAP 1.2 makessignificant progress in addressing this. Hopefully WSDL 1.2will complete this important work. SOAP - REST = Stored Procedures Looking at how other large scale systems cope with updatesprovides some key insights into productive areas for futureresearch with respect to REST. Finally, it bears repeating. Just because a service isusing HTTP GET, doesn't mean that it is REST. If you areencoding parameters on the URL, you are probably making an RPCrequest of a service, not retrieving the representation of aresource. It is worth reading Roy Fielding's thoughts on the subject. The only exception to this rulethat is routinely condoned within the REST crowd is queries. Acknowledgements Thanks go out to MarkBaker , PeterDrayton , SimonFell , and Paul Prescod for their inspiration and input to this essay. Search

dry skin around the

Fixing dry, flaky skin under acne Search iVillage for: Home Join free Horoscopes Quizzes Related Channels: Health | Entertainment | Diet and Fitness | more ... You are here iVillage.co.uk beauty skin care facial care Virtual makeovers Hair care Skin care Make-up & fragrance Body basics Hints, tips and tricks Kickstart 2006 Valentine's beauty D.I.Y. detox Lovely lingerie Win a San Fran trip Fashion forecast Win a weekend in London Blistex Lip Splash Get beautiful nails Win a spa day Spa finder Morning routine quiz Make up matcher Ageing attitude quiz All tools & quizzes Beauty Entertainment Diet and Fitness more newsletters Beauty home Fixing dry, flaky skin under acne Make-up artist to the stars Ross Burton advises on how to conceal dry and flaky skin under acne As one of Lancôme's make-up artists, Ross Burton has had a behind-the-scenes presence at many important fashion shows and photo shoots. He has made up models and movie stars, including Lancôme spokeswoman Uma Thurman. Here Ross shares some great ideas for fixing the dry, flaky skin that often appears under acne. In the morning Step 1: Use an oil-free cleanser to keep the skin's surface clean. Follow with a toner to remove any make-up that remains on the skin. Pat dry and follow with a light, hydrating moisturiser with a pump applicator (to prevent dipping your fingers into anything and transferring it to your face). Step 2: If you wear foundation, use an oil-free formula only in the areas where you need it. Step 3: The biggest mistake women make in concealing acne-prone skin is using too much product as a cover-up. Use a fine-bristle make-up brush to blend three warm shades of concealer to match your skin tone, and apply the concealer with a dotting movement instead of left to right paint strokes. The goal is to diminish the redness and discoloration caused by the pimple(s). Step 4: Set with transparent, oil-free powder to match your skin tone. During the day Step 1: Always carry compact powder for touch-ups. Make sure the puff is not facing the make-up. Keep the plastic piece between the puff and the powder, or turn the puff upside down. Step 2: If the area around your spot(s) becomes visibly dry during the day, apply a clear gel on top of your make-up to keep the area shine-free without over-drying it. In the evening Step 1: Cleanse and tone the skin following the recommended morning routine, and then exfoliate. Exfoliating is an important step because as a blemish dries, there is dry skin around the entire area. An exfoliant removes the excess dry skin. You can exfoliate the whole face or only the areas where you have clogged up and flakey skin. For very clogged skin, exfoliate three times a week. related links ARTICLE: Beauty box: 10 moisturisers put to the test ARTICLE: Caring for combination skin ARTICLE: How to banish blackheads ARTICLE: The pore score ARTICLE: Winter skin protection Get the latest iVillage news on your desktop Sign up for more iVillage RSS feeds iVillage Channels Community Services About iVillage Beauty Diet & Fitness Food & Drink Health Horoscopes Money Motoring News & Showbiz Parenting Pregnancy & Baby Relationships Travel Work & Career Join free Member Centre Competitions eCards Help Instant Games Newsletters Online Dating RSS About Us Privacy Policy Site Map Terms of Service © iVillage Limited 2000-2005. All rights reserved. © iVillage inc. 1995-2005. All rights reserved. 1 -- Fabulous face! Facial washes put to the test Discover the right way to moisturise Try the better skin diet Banish the blemish The five most commonly asked skin care questions answered read this later send to a friend printer friendly