Patients with coronavirus disease 2019 (COVID-19) may have persistent symptoms beyond the normally expected illness resolution. This disease was not diagnosed before late 2019, and therefore, we have more limited experience in understanding all of its outcomes. Thus, clinical, functional, and permanent impairment assessment is challenging. Symptoms including fatigue, dyspnea, and cognitive difficulties have been referred to as “post-acute COVID,” “long COVID,” or “long haulers.” Patients who present for assessment of causation, maximum medical improvement (MMI), and permanent impairment can be challenging. For some examinees, after 6 to 12 months without outgoing improvement and with appropriate investigation, treatment, and rehabilitation, the examinee can be considered at MMI. However, because this disorder is new and appropriate treatment may be unclear, the time to achieve MMI is less certain. Physicians may use approaches in the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), to help define MMI. As science evolves, so will our understanding of how to evaluate chronic problems associated with COVID-19.

The current pandemic of COVID-19 cases includes cases identified in emergency medical technicians, nurses, physicians, and others with occupational exposure to the SARS-CoV-2 virus. Many of these health care professionals have filed workers' compensation claims that have been accepted. Each accepted claim will eventually need a physician to declare the individual “at maximal medical improvement” or the equivalent phrase in the jurisdiction involved. The next step is for the physician to rate permanent impairment, if present, so the case can be administratively closed. The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) is used by many jurisdictions, but the AMA Guides does not mention COVID-19 or have guidance on how to assess individuals for impairment after recovery from this illness. This article provides preliminary guidance on rating permanent impairment within the respiratory, cardiac, vascular, neurologic, renal, gastrointestinal, and/or mental systems in COVID-19 survivors. Current references on the manifestations of COVID-19 illness in these body systems are included, which can be used as references to support documented impairment related to this illness.

The decision about whether a case of documented COVID-19 illness is accepted as occupationally acquired and thus work compensable is made by insurers, or if contested, by judges or administrative bureaus. Causation for COVID-19 may be difficult to show because of the lack of accurate information and difficulty in meeting some of the criteria established by Bradford Hill. Nevertheless, physicians will be asked for medical records and documentation of illness. This article provides preliminary guidance to assist physicians in responding to insurers or workers compensation agencies' requests for information on the medial aspects of COVID-19.

Virtual independent medical evaluations (IMEs) have become and are likely to remain common even after the coronavirus disease 2019 (COVID-19) pandemic ends, but virtual health care and virtual examinations are not simply a matter of moving to a new platform—rather, they require a transformation that affects all stakeholders. Innovative solutions necessitated by virtual IMEs potentially can improve both quality and efficiency. The American Medical Association (AMA) defines telemedicine as health-related services that are synchronous and asynchronous and include a variety of tools and platforms that allow clinicians to connect with one another and patients (a box provides information about AMA's ongoing telehealth initiative). Physicians who plan to perform virtual evaluations must have the appropriate policies, procedures, and security in place; resources are available from the AMA Guides series of publications. Each component of the virtual IME, including each data element, should be assessed to determine best practices and how to use virtual technologies successfully. The credibility of virtual IMEs may hinge on the examiner's ability to explain both what was done and why it was as efficacious as an in-person alternative or perhaps as useful as any other alternative under the circumstances. One challenge is to master the tools used in virtual IMEs and another is to obtain stakeholders' acceptance of the virtual process, but this will come with time, experience, and effective physician performance.

Physicians performing impairment evaluations on patients with cognitive complaints and possible central nervous system disorders should perform a clinical mental status assessment. Assessing cognitive complaints efficiently, in a systematic and supportable way, can be challenging. The AMA Guides to the Evaluation of Permanent Impairment specifies that objective criteria are important to consider when assessing impairment. Physicians may choose to use standardized cognitive screening tests (cognitive screeners) as a relatively quick, practical tool to initially assess patients and aid in decision making. Several cognitive screeners will be discussed in detail below. A patient's performance on such tests may indicate that more comprehensive testing is needed. Cognitive screeners have limitations and are not designed to assess symptom validity or the extent to which psychological factors may contribute to cognitive complaints. Comprehensive neuropsychological assessment may be indicated in these situations and when the screeners demonstrate findings of potential concern help define MMI.