INTRODUCTION: The routine histological assessment of all polyps is costly. A resect and discard small polyp has yet to be used widely in practice. Practically, a 10-year surveillance interval is recommended. Without histological confirmation for these polyps, the surveillance interval may be too long in those with a high-risk adenoma (HRA) since the guidelines recommend the 3-year interval for HRA whereas the 10-year interval for a low-risk adenoma (LRA) and no adenoma. Therefore, we aimed to determine the benefit of this strategy and the risk of hidden HRA and cancer based on only polyp size assessment. METHODS: The electronic database of 7612 screening colonoscopy between January 2007 and February 2019 was retrospectively reviewed. All polyps sized <10 mm were resected and enrolled. In our practice, all identified polyps were resected and sent to a pathologist except diminutive polyps (polyp size <6 mm) at the recto-sigmoid colon would have left. The size of each polyp was estimated by using opened biopsy forceps, which was 7-mm diameter. The location of polyp was classified as the proximal and distal colon. The proximal colon was defined as the region between cecum and the splenic flexure. A HRA was defined as adenoma with high-grade dysplasia, or villous adenoma. A LRA was defined as tubular adenoma. Stratification with polyp size of <6 mm and 6–9 mm, the NPV for diagnosis of a HRA, and number needed for histological assessment (NNH) to detect one HRA were calculated. RESULTS: A total of 5064 polyps <10 mm detected in 4419 subjects were included (Table 1). Of those, size <6 mm was 4211 (83%) and size 6–9 mm was 853 (17%). Histology showed LRA in 3492 (69%) polyps, and HRA in 102 (2%) polyps (Table 1). None had cancer. The prevalence of HRA between proximal polyps and distal polyps was not different (1.7% vs. 2.3%, P = 0.16). Using only polyp size of <6 mm and 6–9 mm, the NPV for diagnosis of HRA were 96.4% and 98.3%, respectively. The NNHs to detect one HRA were 60 in polyp size <6 mm and 28 in polyp size 6–9 mm (Table 2). At $50 per specimen, the polyp size-based resect and discard strategy could save $57,298 for each 1000 subjects with at least one polyp <10 mm. CONCLUSION: In a country with financial constrain, resecting polyp <10 mm without histological assessment is recommended because there was no risk for missing cancer and this strategy achieved the Preservation and Incorporation of Valuable Endoscopic Innovation (PIVI) threshold with NPV at 96% for the HRA.