Tetris Attack is a puzzle video game. The player must use an on-screen cursor to arrange colored blocks into horizontal or vertical rows – matching together three or more blocks of the same color will destroy them. Any blocks above cleared lines will fall, which can be used to cause chain reactions if they touch other matching blocks. The player can also earn combos, clearing more than three blocks in a single move. As the stage progresses, the blocks will begin to rise steadily towards the top of the screen, with new blocks generating from the bottom. Should the blocks touch the top of the playfield, the game will be over.

Several different gameplay modes are included. Story Mode pits the player against a series of computer-controlled opponents. In Endless Mode, the player is challenged to play as long as possible with a continuously rising stack of blocks, which increases in speed over time. Timed Mode challenges the player to score as many points as possible within a two-minute time limit. Stage Clear mode takes the player through a series of stages, in which the objective is to clear all blocks underneath a "boundary" line. In Puzzle Mode, the player must clear all the blocks in a preset block arrangement in a set number of moves – the blocks here do not rise towards the top. Several multiplayer modes are also present with adjustable difficulty levels.