The game is played with the Wii Remote held vertically, with players required to either tap the A button, or squeeze the A and B buttons together. Like previous titles, the game features various levels with their own set of rules, requiring the player to play in time to the rhythm in order to clear them. These levels range from stabbing peas with a fork, to attacking evil spirits with a sword and playing badminton in midair. At the end of each level, players are ranked on their performance, with at least an ‘Okay’ rank required to clear the level and progress onto the next. Each set of levels culminates in a Remix stage, which combines all the gameplay elements of the previous levels in one stage. There are a total of 50 levels divided across 10 sets.
Clearing levels with a Superb/High Level rating earns medals which unlock extra content, including Rhythm Toys, Endless Minigames and levels from the original Rhythm Tengoku. Levels that have been cleared with a Superb rating may also be randomly selected for a Perfect attempt, in which the player can try to clear the level without making any mistakes with the maximum of 3 retries before the perfect challenge disappear.
New to the series (bar the Arcade version of Rhythm Tengoku) is a multiplayer mode, in which two players can play simultaneously. Levels played in multiplayer require players to earn enough points in total to reach the desired rank and clear each stage, with bonus points awarded based on the harmony of the players. These levels come with their own set of medals which can unlock multiplayer minigames.