Step-by-step: which algorithm, when to excise, when to refer, MBS items, and what to tell the patient
Sources
1. RACGP. Clinical guideline for the diagnosis and management of melanoma. Cancer Council Australia & RACGP. cancercouncil.com.au/clinical-guidelines/melanoma
2. Glasgow 7-Point Checklist — MacKie RM. Clinical recognition of early invasive malignant melanoma. BMJ. 1990.
3. ABCDE criteria — Friedman RJ, Rigel DS, Kopf AW. Early detection of malignant melanoma. CA Cancer J Clin. 1985.
4. Chaos & Clues — Kittler H et al. Dermoscopy. 3rd edition. 2016.
5. Menzies Method — Menzies SW et al. A sensitivity and specificity analysis of the surface microscopy features of invasive melanoma. Melanoma Res. 1996.
6. MBS Book July 2026 — item 30071 (diagnostic skin biopsy) and the 31356–31383 series (skin excision). mbsonline.gov.au
Disclaimer: This workflow is a clinical reference tool, not a diagnostic algorithm. All suspicious lesions require clinical assessment by a qualified practitioner. MBS fees from July 2026 — verify at mbsonline.gov.au.
RACGP Guidelines 2025MBS Book July 2026Tier 1 — verified
Step 1 — Immediate urgency assessment
What is your initial clinical impression?
⚠️ Urgent — do not delay excision or referral
Nodular, ulcerated, bleeding, rapidly growing, or fixed/hard lesions require urgent management. In Australia, nodular melanoma is responsible for a disproportionate share of melanoma deaths because it grows quickly and does not follow the typical ABCDE pattern.
GP with excision capability: Excise with 2mm clinical margin urgently (excision biopsy). Do not shave or punch biopsy — full excision for histopathology.
Refer urgently: If uncertain about excision or patient declines — urgent dermatology or surgical referral.
🟡 Suspicious — proceed to formal scoring then decision
A suspicious lesion should be formally scored using a validated algorithm before deciding management. Move to Step 2 to choose the most appropriate tool for this lesion type.
If clinically benign (typical seborrhoeic keratosis, dermatofibroma, clear angioma), formal scoring is still useful to document your assessment. If you or the patient have any doubt — score it formally. Photograph and document for baseline if reviewing.
Seborrhoeic keratosis: stuck-on appearance, horn pseudocysts, no risk of malignancy
All five algorithms are available in the Skin Lesion Scoring tool with interactive scoring and interpretation. Source: algorithms from validated literature cited within each tool.
Step 3 — Management decision
Based on your clinical assessment and scoring:
✂️ Excision in GP — key points
Excision biopsy (not shave, not punch) for any potentially malignant pigmented lesion
2mm clinical margin for suspected melanoma — widen after histology confirms melanoma and thickness
Mark orientation on specimen (suture at 12 o'clock) to guide re-excision if positive margins
Submit ALL tissue for histopathology — do not discard
Semi-urgent (2–4 weeks): High ABCDE or 7-point score, dermoscopic uncertainty, positive Chaos
Routine: Multiple atypical naevi requiring surveillance, patient with melanoma history, large congenital naevi
Refer to: Dermatologist (1st choice for diagnostic uncertainty), plastic surgeon (complex sites — face, ear, acral), or general surgeon with skin cancer interest. Use patient mole check prep guide to help them prepare for the referral.
📷 Monitoring — document carefully
Only appropriate for genuinely low-suspicion lesions after formal scoring
Photograph with ruler in frame — dermoscopy photograph preferred
Document all features at baseline: site, dimensions, ABCDE score, reason for monitoring over excision
Review at 3 months (any change = excise). Annual review thereafter if stable
Warn patient explicitly: any change in size, shape, colour, bleeding — attend sooner
Actinic keratoses (AK): 5-fluorouracil cream (Efudix), imiquimod (Aldara), or diclofenac gel. Cryotherapy for isolated AKs. Photodynamic therapy (PDT) via dermatologist for field cancerisation.
Superficial BCC: Imiquimod (Aldara) — 5×/week for 6 weeks. Not suitable for nodular BCC, morphoeic BCC, or facial BCC. Confirm histological diagnosis first.
Field cancerisation: Document extent, photograph, use structured monitoring
MBS skin excision items are organised by anatomical area (not just lesion size), with separate items for malignant, non-malignant, melanoma, and suspected melanoma. Excision item, fee, repair codes, and co-claiming rules are all in one place:
For diagnostic biopsy only (punch or shave biopsy where definitive excision is not yet planned) — use item 30071 · schedule fee $62.55 · 85% benefit $51.85. Source: MBS Book July 2026, item 30071.