BBPS is scored after you have washed and suctioned, not on insertion. Each of three segments gets 0 to 3. Adequate for a 10-year screening interval is a total of 6 or more with no segment under 2. A segment that stays 0 or 1 is an inadequate exam. Split-dose is how you get there. A perfect 9 is a different, narrower argument on the companion page.

Experienced teaching points

Clinical Pearls

Score after washing. Insertion stool that you then clear does not count against the segment.
0 unprepared, 1 residual stool that still hides mucosa, 2 minor liquid after suction, 3 whole mucosa seen.
Adequate: total 6 or more and every segment at least 2 (Calderwood 2014). A leftover 1 in the right colon is not a 6 that you can talk yourself into.
Split-dose, last dose 4-6 hours before the scope, finished at least 2 hours prior (USMSTF 2014).

Clinical Bottom Line

Question	Practical answer
When do I score?	After washing and suctioning that segment. BBPS is an inspection score, not an arrival score (Lai 2009, PMID 19136102).
What do 0-3 mean?	0: unprepared mucosa, solid stool you cannot clear. 1: portions of mucosa seen, residual staining or stool still hides wall. 2: minor residual liquid, mucosa seen well after suction. 3: entire mucosa seen, no residual staining.
What is adequate?	Total 6 or more with every segment at least 2. That is the definition most US endoscopists already use for a 10-year screening follow-up (Calderwood 2014, PMID 24629422).
When do I repeat soon?	Any segment 0, and almost always any segment that stays 1 after a real wash. Total 0-2: within a year. Totals 3-5 are the messy middle. Do not assign 10 years.
How do I get a 6?	Split-dose. Same-day is acceptable for afternoon lists. Last dose 4-6 hours before the scope (Johnson USMSTF 2014, PMID 25239068).

Why did BBPS replace fair and poor?

Lai 2009 built a 0-9 scale that is scored after cleaning maneuvers, then showed it was reliable on video and that higher scores tracked polyp detection. Calderwood 2010 (PMID 20883845) showed that physicians would call an exam adequate to exclude polyps larger than 5 mm once the total reached 6, and that totals under 5 triggered a 1-year repeat in every rater. The point was never to invent a vanity metric. It was to stop writing "fair prep" on a chart that later has to justify a 10-year interval.

Calderwood 2014 then asked what endoscopists actually do with real screening exams. If every segment was at least 2 (almost always a total of 6 or more), 90% of negative screens were given 10 years. Totals 0-2 were repeated within a year 96% of the time. Totals 3-5 were chaos. That is still the clinical map.

What does adequate mean on a quality dashboard?

ACG/ASGE 2024 (Rex, PMID 39167112) still wants an adequate-prep rate of at least 90% on the screening and surveillance list. Adequate in that document is a prep that lets you follow the usual interval. In BBPS language, that is total 6 or more and no segment under 2. Dashboard: colonoscopy quality page.

A 2 is not a dirty colon. It is residual liquid you can suction. Do not withhold a 10-year interval because the right colon was 2 instead of 3 if you actually saw the mucosa. The case for chasing a 3 in the right colon is SSL detection, and that argument lives on the BBPS 9 page.

How do I get the score up?

USMSTF 2014 (Johnson, PMID 25239068): split-dose for elective colonoscopy. The second half starts 4-6 hours before the procedure and finishes at least 2 hours before. Same-day dosing is an alternative for afternoon cases. Day-before-only prep leaves small-bowel chyme in the right colon. That is how a "good" left colon hides a mucus-capped SSL.

In the room: wash, suction, then score. A right-colon 1 that becomes a 2 after two minutes of water is a 2. A right-colon 1 that is still a 1 after you have tried is an inadequate segment. Write the three numbers, not a vibe.

Selected references

Last reviewed September 20, 2026. Written for clinicians assigning a surveillance interval after today's colonoscopy, and for the ones still dictating fair or poor.

Topics

Colonoscopy

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