High-hardness iron-based alloy coatings are extensively utilized in aerospace, automotive, and industrial equipment due to their exceptional wear resistance and long service life. Laser cladding has emerged as one of the primary techniques for fabricating these coatings, owing to its rapid cooling and dense microstructure characteristics. However, the production of high-hardness iron-based alloy coatings via laser cladding continues to face numerous challenges, particularly when controlling the morphology, quantity, and distribution of the reinforcing phases, which can lead to cracking during processing and service, thus compromising their usability. The cracks of the cladding layer will be suppressed through good microstructure design and control, resulting in a wide range of performance for high-hardness Fe-based alloy coatings. This paper reviews recent advancements in the design and control of the organization and structure of high-hardness iron-based alloy coatings from the perspectives of material composition, processing parameters, and external assistance techniques. It summarizes the properties and applications of various materials, including different alloying elements, ceramic particles, and rare earth oxides, while systematically discussing how processing parameters influence microstructure and performance. Additionally, the mechanisms by which external auxiliary energy fields affect the melt pool and solidified microstructure during laser cladding are elucidated. Finally, the future development directions of laser cladding technology for high-hardness iron-based coatings are anticipated, emphasizing the need for further quantification of the optimal coupling relationships among the gain effects of composite energy fields.